Provider Demographics
NPI:1689973703
Name:WISMAN, CRAIG BURTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:BURTON
Last Name:WISMAN
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 1:1024 MOUNT ALEM DR
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-8900
Mailing Address - Country:US
Mailing Address - Phone:717-756-6781
Mailing Address - Fax:717-566-1820
Practice Address - Street 1:1024 MOUNT ALEM DR
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-8900
Practice Address - Country:US
Practice Address - Phone:717-756-6781
Practice Address - Fax:717-566-1820
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 023770 E208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0911578Medicaid
B38998Medicare UPIN
WI140089Medicare PIN