Organization
CLEVELAND MEDICAL CLINIC FAMILY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PHILIP R WISIACKAS MD (PHYSICIAN)
(281) 592-3600
Entity
Organization
Contact information
Practice address
208 N BONHAM AVE, CLEVELAND, TX 77327-4023
(281) 592-3600
Mailing address
208 N BONHAM AVE, CLEVELAND, TX 77327-4023
(281) 592-3600
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
F4703
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
126965602
—
TX
Enumeration date
10/27/2006
Last updated
02/02/2010
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