Provider Demographics
NPI:1487622163
Name:WYSHOCK, EDWARD GERARD (MD, FACP)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GERARD
Last Name:WYSHOCK
Suffix:
Gender:M
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1909
Practice Address - Country:US
Practice Address - Phone:570-326-8470
Practice Address - Fax:570-326-8590
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024756E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B29966Medicare UPIN
PA1768391OtherUNITEDHEALTHCARE
PA0009056790003Medicaid
PA50057107OtherKEYSTNE HLTH PLN CENTRAL
PAP00071998Medicare PIN
PAB29966OtherHEALTHAMERICA
PA003870Medicare PIN
PA823001OtherFIRST PRIORITY HEALTH
PA003870OtherHIGHMARK BLUE SHIELD
B29966Medicare UPIN
PA4202844OtherAETNA
PAP00624243Medicare PIN