Provider Demographics
NPI:1942279039
Name:PHILIP WISOTSKY M.D., P.C.
Entity Type:Organization
Organization Name:PHILIP WISOTSKY M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-870-0660
Mailing Address - Street 1:12070 OLD LINE CENTRE #207
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2567
Mailing Address - Country:US
Mailing Address - Phone:301-870-0660
Mailing Address - Fax:301-932-8310
Practice Address - Street 1:12070 OLD LINE CENTRE #207
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2567
Practice Address - Country:US
Practice Address - Phone:301-870-0660
Practice Address - Fax:301-932-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD18548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX IDENTIFICATION
MD611LMedicare PIN