Provider Demographics
NPI:1942437710
Name:WISTERIA MEDICAL CARE, PC
Entity Type:Organization
Organization Name:WISTERIA MEDICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-353-2121
Mailing Address - Street 1:136-30 MAPLE AVENUE
Mailing Address - Street 2:SUITE #2I
Mailing Address - City:FLUSHING, QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3865
Mailing Address - Country:US
Mailing Address - Phone:718-353-2121
Mailing Address - Fax:718-353-7621
Practice Address - Street 1:136-30 MAPLE AVENUE
Practice Address - Street 2:SUITE #2I
Practice Address - City:FLUSHING, QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11355-3865
Practice Address - Country:US
Practice Address - Phone:718-353-2121
Practice Address - Fax:718-353-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203178207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04661756Medicaid
NYF98922Medicare UPIN