Basic Information
| Provider Information | |||||||||
| NPI: | 1518237452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISTREICH | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEGG | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 8500-8482 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191788482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157829 | ||||||||
| FaxNumber: | 6098157814 | ||||||||
| Practice Location | |||||||||
| Address1: | 570 SOUTH AVE E UNIT A | ||||||||
| Address2: | |||||||||
| City: | CRANFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070163200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082727990 | ||||||||
| FaxNumber: | 9082727970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2012 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 223378948 | NJ | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 25MB09128600 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0299073 | 05 | NJ | MEDICAID |