Provider Demographics
NPI:1487681722
Name:HALPHEN LASSO, GISELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:MARIE
Last Name:HALPHEN LASSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GISELLE
Other - Middle Name:MARIE
Other - Last Name:HALPHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-371-5763
Mailing Address - Fax:888-241-1404
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-9403
Practice Address - Fax:215-225-1698
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017443500002Medicaid
PA2854904000OtherINDEPENDENCE BCBS
PA1017443500003Medicaid
PA1017443500001Medicaid
PA2089055OtherHIGHMARK BLUE SHIELD
PA1017443500001Medicaid