Provider Demographics
NPI:1760420632
Name:WALLISCH, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:WALLISCH
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 1:900 BRYAN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2413
Mailing Address - Country:US
Mailing Address - Phone:814-643-6207
Mailing Address - Fax:814-643-6165
Practice Address - Street 1:850 WALNUT BOTTOM RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-3632
Practice Address - Country:US
Practice Address - Phone:814-643-6207
Practice Address - Fax:814-643-6165
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033581E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010634900001Medicaid
PAMD033581EOtherLICENSE
PA0010634900001Medicaid