Provider Demographics
NPI:1336232255
Name:NIKSCH, ALISA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:LOUISE
Last Name:NIKSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:750 WASHINGTON ST
Mailing Address - Street 2:THE FLOATING HOSPITAL FOR CHILDREN, #313
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1526
Mailing Address - Country:US
Mailing Address - Phone:617-636-5067
Mailing Address - Fax:617-636-2354
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:THE FLOATING HOSPITAL FOR CHILDREN, #313
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-5067
Practice Address - Fax:617-636-2354
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0361164682080P0202X
MA2437472080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA243747Medicaid
IL036116468Medicaid