Healthcare Provider Details

I. General information

NPI: 1144279308
Provider Name (Legal Business Name): ROBERT WILLIAM WISHTISCHIN MSPT, SCS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 RESERVOIR AVE
CRANSTON RI
02910-4430
US

IV. Provider business mailing address

721 RESERVOIR AVE
CRANSTON RI
02910-4430
US

V. Phone/Fax

Practice location:
  • Phone: 401-946-4250
  • Fax: 401-275-5645
Mailing address:
  • Phone: 401-946-4250
  • Fax: 401-275-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5367
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02580
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: