Provider Demographics
NPI:1437235116
Name:CLEVELAND MEDICAL CLINIC FAMILY
Entity Type:Organization
Organization Name:CLEVELAND MEDICAL CLINIC FAMILY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:WISIACKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-592-3600
Mailing Address - Street 1:208 N BONHAM AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327-4023
Mailing Address - Country:US
Mailing Address - Phone:281-592-3600
Mailing Address - Fax:
Practice Address - Street 1:208 N BONHAM AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4023
Practice Address - Country:US
Practice Address - Phone:281-592-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126965602Medicaid
TX453967Medicare ID - Type Unspecified
TXE28279Medicare UPIN