MEDICARE: DR. AISA G LOPEZ M.D.

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	225400000X	Rehabilitation Practitioner	MD-038064L	PA

General Provider Information

NPI Number	:	1942240700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AISA G LOPEZ M.D.

Provider Business Mailing Address
First Line	:	8046 CRITTENDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-2909
Country	:	US
Telephone Number	:	215-248-0209
Fax Number	:	215-247-1286

Provider Business Practice Location Address
First Line	:	5800 RIDGE AVE
Second Line	:	ROXBOROUGH MEMORIAL HOSPITAL REHABILITATION DEPARTMENT
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1737
Country	:	US
Telephone Number	:	215-487-4718
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/08/2007

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