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General NPI Number Information
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NPI Number | 1437235116
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Entity Type | Organization
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Legal Business Name | CLEVELAND MEDICAL CLINIC FAMILY
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 02/02/2010
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Provider Practice Location Address
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Address Line | 208 N BONHAM AVE
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City | CLEVELAND
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State | TX
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Zip | 77327-4023
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Country | US
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Telephone | 281-592-3600
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Fax |
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Provider Business Mailing Address
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Address Line | 208 N BONHAM AVE
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City | CLEVELAND
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State | TX
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Zip | 77327-4023
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Country | US
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Telephone | 281-592-3600
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. PHILIP R WISIACKAS
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Credential | MD
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Telephone | 281-592-3600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | F4703
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License Number State | TX
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