MEDICARE: DR. DIANE CHISESI NFS. MD. PHD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	218974772	CO
2	207P00000X	Emergency Medicine Physician	218974772	CO
3	207ZF0201X	Forensic Pathology Physician	218974772	CO
4	207ZH0000X	Hematology (Pathology) Physician	218974772	CO
5	2080P0204X	Pediatric Emergency Medicine (Pediatrics) Physician	218974772	CO
6	208600000X	Surgery Physician	218974772UA	CO
7	2086X0206X	Surgical Oncology Physician	218974772	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	218974772	OTHER	CO	DHP/HSSA/DSS

General Provider Information

NPI Number	:	1508291956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE CHISESI NFS. MD. PHD.

Provider Business Mailing Address
First Line	:	P.O. BOX 6936
Second Line	:	2517 B. KING STREET
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904
Country	:	US
Telephone Number	:	719-477-0295
Fax Number	:

Provider Business Practice Location Address
First Line	:	2517 B. KING STREET
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904
Country	:	US
Telephone Number	:	719-477-0295
Fax Number	:	719-477-0295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2013
Last Update Date	:	09/09/2013

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