Provider Demographics
NPI:1538188073
Name:WYNNE, CRAIG S (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:S
Last Name:WYNNE
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 1:3701 MARKET ST
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3701 MARKET ST
Practice Address - Street 2:SUITE 560W
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5502
Practice Address - Country:US
Practice Address - Phone:215-662-2250
Practice Address - Fax:215-615-3995
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048550L208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001462547Medicaid
PAF78941Medicare UPIN
PA767478Medicare PIN