Provider Demographics
NPI:1386791176
Name:ALISANSKI, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ALISANSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3000
Mailing Address - Fax:239-596-1661
Practice Address - Street 1:5450 YMCA RD STE 102
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-5944
Practice Address - Country:US
Practice Address - Phone:239-658-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1135362080H0002X, 2080P0207X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006387100Medicaid