Provider Demographics
NPI:1861459000
Name:WISGO, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:WISGO
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:PO BOX 8500-6335
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-6335
Mailing Address - Country:US
Mailing Address - Phone:215-612-4963
Mailing Address - Fax:215-612-4532
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1445
Practice Address - Country:US
Practice Address - Phone:215-612-4963
Practice Address - Fax:215-612-4532
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057309L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0870310000OtherKEYSTONE
PA30010341OtherKEYSTONE MERCY
PA0016034670008OtherPROMISE
PA838274OtherBS
PA001603467Medicaid
PA0870310000OtherKEYSTONE
PAG35725Medicare UPIN