Basic Information
| Provider Information | |||||||||
| NPI: | 1881629269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KESSELMAN | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740177 | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334740177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617402900 | ||||||||
| FaxNumber: | 5614340598 | ||||||||
| Practice Location | |||||||||
| Address1: | 6944 LAKE WORTH RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614340060 | ||||||||
| FaxNumber: | 5614340598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 10/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD26427 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | ME0060547 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 055256900 | 05 | FL | MEDICAID |