MEDICARE: MATTHEW S WISHNOFF

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1831741321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW S WISHNOFF

Provider Business Mailing Address
First Line	:	1501 N LARRABEE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1119
Country	:	US
Telephone Number	:	312-330-1861
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 E MARSHALL ST
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23298-5026
Country	:	US
Telephone Number	:	804-828-9788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	07/15/2019

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