1134121577 NPI number — DR. RICHARD E WYSZYNSKI M.D.

Table of content: DR. RICHARD E WYSZYNSKI M.D. (NPI 1134121577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134121577 NPI number — DR. RICHARD E WYSZYNSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYSZYNSKI
Provider First Name:
RICHARD
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134121577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4676 DOUGLAS CIR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44718-3619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-494-1116
Provider Business Mailing Address Fax Number:
330-494-0276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4676 DOUGLAS CIR NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44718-3619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-494-1116
Provider Business Practice Location Address Fax Number:
330-494-0276
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  35-054663-W , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X , with the licence number: 35.054663 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 80523 . This is a "QUALCHOICE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0800331 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 180011157 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 574789 . This is a "KEYSTONE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: M54663 . This is a "SUMMACARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4125776 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000126323 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0011833800001 . This is a "MEDICAID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0808602 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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