Basic Information
| Provider Information | |||||||||
| NPI: | 1629693718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALISZEWSKI | ||||||||
| FirstName: | MIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVE. | ||||||||
| Address2: | ROOM 202 MAIN HOSPITAL MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVE. | ||||||||
| Address2: | ROOM 202 MAIN HOSPITAL MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923072 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | LL84448 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.