MEDICARE: SHEPHERD RURAL HEALTH CLINIC PA

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	363A00000X	Physician Assistant	F4703	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376629212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEPHERD RURAL HEALTH CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 669
Second Line	:
City	:	SHEPHERD
State	:	TX
Zip	:	77371-0669
Country	:	US
Telephone Number	:	936-628-3343
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 WOODLAND PARK DRIVE
Second Line	:
City	:	SHEPHERD
State	:	TX
Zip	:	77371
Country	:	US
Telephone Number	:	936-628-3343
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. PHILIP R WISIACKAS
Credential	:	MD
Telephone Number	:	936-628-3343

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	08/30/2010

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