Basic Information
| Provider Information | |||||||||
| NPI: | 1700874146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILCZANSKI | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | LUKASZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 STATE ST | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144807100 | ||||||||
| FaxNumber: | 8144807604 | ||||||||
| Practice Location | |||||||||
| Address1: | 5241 BUFFALO RD | ||||||||
| Address2: | LAKESHORE FAMILY PRACTICE | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165102309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148777686 | ||||||||
| FaxNumber: | 8148777692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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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 | MD040751L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00025573901 | 01 | NY | UNIVERA | OTHER | 0011180320003 | 05 | PA | MEDICAID | 080081947 | 01 | PA | RR MEDICARE | OTHER | 66429 | 01 | PA | UNISON | OTHER | P000383 | 01 | PA | GATEWAY | OTHER | 212709 | 01 | PA | UPMC | OTHER | 522615 | 01 | PA | AETNA | OTHER | 01917019 | 01 | NY | NY MEDICAID | OTHER | 015973 | 01 | PA | BLUE SHIELD | OTHER |