Provider Demographics
NPI:1982659611
Name:COMPLETE PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:COMPLETE PHYSICIAN SERVICES
Other - Org Name:FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-533-1333
Mailing Address - Street 1:1216 E HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124
Mailing Address - Country:US
Mailing Address - Phone:215-533-1333
Mailing Address - Fax:215-744-4324
Practice Address - Street 1:1216 E HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124
Practice Address - Country:US
Practice Address - Phone:215-533-1333
Practice Address - Fax:215-744-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS4457L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
152136FW0Medicare ID - Type Unspecified
E06299Medicare UPIN