Basic Information
| Provider Information | |||||||||
| NPI: | 1881625978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRANBERRY INTERNAL MEDICINE ASSOC.,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20826 ROUTE 19 | ||||||||
| Address2: | |||||||||
| City: | CRANBERRY TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160666028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247764776 | ||||||||
| FaxNumber: | 7247760251 | ||||||||
| Practice Location | |||||||||
| Address1: | 20826 ROUTE 19 | ||||||||
| Address2: | |||||||||
| City: | CRANBERRY TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 160666028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7247764776 | ||||||||
| FaxNumber: | 7247760251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WUSYLKO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7247764776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD021760E | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.