Basic Information
Provider Information | |||||||||
NPI: | 1659369551 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOSASSO | ||||||||
FirstName: | ALISA | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALFONSI | ||||||||
OtherFirstName: | ALISA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 191 | ||||||||
Address2: |   | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197230191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026516212 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Practice Location | |||||||||
Address1: | 833 CHESTNUT STREET EAST | ||||||||
Address2: | SUITE 300 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2158618830 | ||||||||
FaxNumber: | 2158618833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2005 | ||||||||
LastUpdateDate: | 09/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD074378L | PA | Y |   | Allopathic & Osteopathic Physicians | General Practice |   | 208000000X | MD074378L | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 0019062780007 | 05 | PA |   | MEDICAID |