Provider Demographics
NPI:1427188937
Name:JOHN J. WASNIEWSKI JR. DO PC
Entity Type:Organization
Organization Name:JOHN J. WASNIEWSKI JR. DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WASNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-271-0101
Mailing Address - Street 1:2136 W PASSYUNK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-3415
Mailing Address - Country:US
Mailing Address - Phone:215-271-0101
Mailing Address - Fax:215-334-7259
Practice Address - Street 1:2136 W PASSYUNK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-3415
Practice Address - Country:US
Practice Address - Phone:215-271-0101
Practice Address - Fax:215-334-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005923960004Medicaid
PA107718OtherMEDICARE ID
PA1598762402OtherNPI PRIVATE PROVIDER
PA0005923960004Medicaid