Individual
DR. CHARLES WISNIEWSKI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
4641 ROOSEVELT BLVD, PHILADELPHIA, PA 19124-2343
(215) 831-2600
Mailing address
4641 ROOSEVELT BLVD STE E223, PHILADELPHIA, PA 19124-2343
(631) 831-4053
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
OS019121
PA
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1770997587
—
PA
Enumeration date
06/19/2014
Last updated
10/12/2018
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