MEDICARE: MAX WASSERMAN

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1770041063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAX WASSERMAN

Provider Business Mailing Address
First Line	:	123 SLOCUM AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2253
Country	:	US
Telephone Number	:	314-550-5866
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 SLOCUM AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2253
Country	:	US
Telephone Number	:	314-550-5866
Fax Number	:

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

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	03/06/2019

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