Healthcare Provider Details

I. General information

NPI: 1922157593
Provider Name (Legal Business Name): PETER L WISNIEWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 PRINCE FREDERICK BLVD STE 201
PRINCE FREDERICK MD
20678-3492
US

IV. Provider business mailing address

985 PRINCE FREDERICK BLVD STE 201
PRINCE FREDERICK MD
20678-3492
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-2005
  • Fax: 410-535-4850
Mailing address:
  • Phone: 410-535-2005
  • Fax: 410-535-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD40370
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberD40370
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: