Basic Information
| Provider Information | |||||||||
| NPI: | 1063431393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHWIECKO | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JEROME | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13579 | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196123579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846280799 | ||||||||
| FaxNumber: | 4843347026 | ||||||||
| Practice Location | |||||||||
| Address1: | 950B N WYOMISSING BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196101783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846282490 | ||||||||
| FaxNumber: | 6102884515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD065926L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001708594 | 05 | PA | MEDICAID |