MEDICARE: PHILIP R. WISIACKAS, M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F4703	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00FS32	OTHER	TX	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1174838411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILIP R. WISIACKAS, M.D., P.A.

Provider Business Mailing Address
First Line	:	110 HILL AVE
Second Line	:
City	:	COLDSPRING
State	:	TX
Zip	:	77331-5406
Country	:	US
Telephone Number	:	936-653-4223
Fax Number	:	936-653-5042

Provider Business Practice Location Address
First Line	:	110 HILL AVE
Second Line	:
City	:	COLDSPRING
State	:	TX
Zip	:	77331-5406
Country	:	US
Telephone Number	:	936-653-4223
Fax Number	:	936-653-5042

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	PHILIP ROBERT WISIACKAS
Credential	:	MD
Telephone Number	:	936-653-4223

Provider Enumeration Date	:	08/11/2010
Last Update Date	:	04/07/2011

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