Provider Demographics
NPI:1154472579
Name:WISNIEWSKI, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W AIRPARK RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15926-9221
Mailing Address - Country:US
Mailing Address - Phone:814-754-1974
Mailing Address - Fax:
Practice Address - Street 1:340 1ST ST
Practice Address - Street 2:
Practice Address - City:CONEMAUGH
Practice Address - State:PA
Practice Address - Zip Code:15909-1906
Practice Address - Country:US
Practice Address - Phone:814-535-7721
Practice Address - Fax:814-535-2105
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042330L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1526828OtherGATEWAY HEALTHPLAN
PA0487180000OtherINDENPENDANCE BLUE SHEILD
101310OtherUPMC HEALTHPLAN
110082629OtherRAILROAD MEDICARE
PA654889OtherHIGHMARK BLUE SHIELD
PA0012353890004Medicaid
327740OtherHEALTH AMERICA
5317328OtherAETNA
1526828OtherGATEWAY HEALTHPLAN
5317328OtherAETNA
PA0487180000OtherINDENPENDANCE BLUE SHEILD