Provider Demographics
NPI:1821283912
Name:DR. SHOUKRI M. WISA MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:DR. SHOUKRI M. WISA MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOUKRI
Authorized Official - Middle Name:MINA
Authorized Official - Last Name:WISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-343-6363
Mailing Address - Street 1:164 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-2113
Mailing Address - Country:US
Mailing Address - Phone:585-343-6363
Mailing Address - Fax:585-343-1986
Practice Address - Street 1:164 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2113
Practice Address - Country:US
Practice Address - Phone:585-343-6363
Practice Address - Fax:585-343-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01127023Medicaid
NYAA1309Medicare PIN