Basic Information
| Provider Information | |||||||||
| NPI: | 1033136015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIZNITZER | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866295 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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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 | 2084N0402X | 35-043073 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 000000526174 | 01 | OH | ANTHEM | OTHER | 0013055270003 | 05 | PA | MEDICAID | 000000028264 | 01 | OH | ANTHEM | OTHER | P00445001 | 01 | OH | RAILROAD MEDICARE | OTHER | 0631598 | 01 | OH | BCMH | OTHER | 0631598 | 05 | OH | MEDICAID | 731878 | 01 | OH | BUCKEYE | OTHER | 000000221332 | 01 | OH | UNISON | OTHER | 0640754 | 01 | OH | AETNA | OTHER | 1033136015 | 05 | MI | MEDICAID | 364144 | 01 | OH | WELLCARE | OTHER |