Provider Demographics
NPI:1538941117
Name:WISTERIA PAIN AND SPINE LLC
Entity type:Organization
Organization Name:WISTERIA PAIN AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ACHARTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-722-9074
Mailing Address - Street 1:2401 W CHELTENHAM AVE STE 312
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-2946
Mailing Address - Country:US
Mailing Address - Phone:215-722-9074
Mailing Address - Fax:445-269-5619
Practice Address - Street 1:2401 W CHELTENHAM AVE STE 312
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2946
Practice Address - Country:US
Practice Address - Phone:445-300-7313
Practice Address - Fax:445-269-5619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty