Provider Demographics
NPI:1881625978
Name:CRANBERRY INTERNAL MEDICINE ASSOC.,LLC
Entity type:Organization
Organization Name:CRANBERRY INTERNAL MEDICINE ASSOC.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WUSYLKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-776-4776
Mailing Address - Street 1:20826 ROUTE 19
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6028
Mailing Address - Country:US
Mailing Address - Phone:724-776-4776
Mailing Address - Fax:724-776-0251
Practice Address - Street 1:20826 ROUTE 19
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-6028
Practice Address - Country:US
Practice Address - Phone:724-776-4776
Practice Address - Fax:724-776-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021760E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA026496Medicare ID - Type Unspecified
PAB39323Medicare UPIN
PAWU142583Medicare ID - Type Unspecified
PAG91387Medicare UPIN
PA026536Medicare ID - Type Unspecified