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General NPI Number Information
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NPI Number | 1649717364
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Entity Type | Organization
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Legal Business Name | COMPLETE PHYSICIAN SERVICES
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Dates
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Enumeration Date | 01/20/2017
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Last Update Date | 01/20/2017
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Provider Practice Location Address
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Address Line | 1216 E HUNTING PARK AVE # 1
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City | PHILADELPHIA
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State | PA
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Zip | 19124-4928
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Country | US
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Telephone | 215-533-1333
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Fax |
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Provider Business Mailing Address
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Address Line | 1216 E HUNTING PARK AVE # 1
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City | PHILADELPHIA
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State | PA
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Zip | 19124-4928
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Country | US
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Telephone |
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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. KENNETH WISEMAN
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Credential |
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Telephone | 215-533-1333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OA004049
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License Number State | PA
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