Provider Demographics
NPI:1538111034
Name:WASSERSTROM, MICHAEL SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:WASSERSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 OLD VINES DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8533
Mailing Address - Country:US
Mailing Address - Phone:317-896-3304
Mailing Address - Fax:
Practice Address - Street 1:120 E CARMEL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2633
Practice Address - Country:US
Practice Address - Phone:317-844-7000
Practice Address - Fax:317-844-3268
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001875A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200249330AMedicaid
IN000000175475OtherANTHEM PIN #
IN146500BMedicare PIN
IN000000175475OtherANTHEM PIN #