Provider Demographics
NPI:1386676617
Name:WISSER, MICHAEL R (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:WISSER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:145 BRINTON LAKE ROAD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342
Mailing Address - Country:US
Mailing Address - Phone:610-459-1619
Mailing Address - Fax:610-459-1865
Practice Address - Street 1:145 BRINTON LAKE RD
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-2281
Practice Address - Country:US
Practice Address - Phone:610-459-1619
Practice Address - Fax:610-459-1865
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-08-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOS009968L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017882270001Medicaid
PA0017882270001Medicaid
H04989Medicare UPIN