1154472579 NPI number — DR. JOHN MICHAEL WISNIEWSKI M.D.

Table of content: DR. JOHN MICHAEL WISNIEWSKI M.D. (NPI 1154472579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154472579 NPI number — DR. JOHN MICHAEL WISNIEWSKI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISNIEWSKI
Provider First Name:
JOHN
Provider Middle Name:
MICHAEL
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:
1154472579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONEMAUGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15909-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-535-7721
Provider Business Mailing Address Fax Number:
814-535-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONEMAUGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15909-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-535-7721
Provider Business Practice Location Address Fax Number:
814-535-2105
Provider Enumeration Date:
01/13/2007

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: 207R00000X , with the licence number:  MD042330L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1526828 . This is a "GATEWAY HEALTHPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 654889 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0487180000 . This is a "INDENPENDANCE BLUE SHEILD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 101310 . This is a "UPMC HEALTHPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 327740 . This is a "HEALTH AMERICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110082629 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0012353890004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5317328 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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