Basic Information
| Provider Information | |||||||||
| NPI: | 1437495421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICELINSKI | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | 6078731244 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 ROE AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077374508 | ||||||||
| FaxNumber: | 6077355738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 277455 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 277455 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207P00000X | 277455 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04665532 | 05 | NY | MEDICAID |