Provider Demographics
NPI:1194915389
Name:WIRTH, PHILIPP C (MD)
Entity type:Individual
Prefix:
First Name:PHILIPP
Middle Name:C
Last Name:WIRTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MASON ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1133
Mailing Address - Country:US
Mailing Address - Phone:315-230-5646
Mailing Address - Fax:315-230-5645
Practice Address - Street 1:369 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1654
Practice Address - Country:US
Practice Address - Phone:315-539-4025
Practice Address - Fax:315-539-4128
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00438901Medicare PIN
NYRB5814Medicare PIN