1053728634 NPI number — WISECARE, LLC

Table of content: (NPI 1053728634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053728634 NPI number — WISECARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISECARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053728634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 MAGOTHY BEACH RD
Provider Second Line Business Mailing Address:
SUITE 102-103
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21122-4413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-255-7900
Provider Business Mailing Address Fax Number:
410-255-7300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 MAGOTHY BEACH RD
Provider Second Line Business Practice Location Address:
SUITE 102-103
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-255-7900
Provider Business Practice Location Address Fax Number:
410-255-7300
Provider Enumeration Date:
07/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WEISMAN
Authorized Official First Name:
PERRY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
267-252-7220

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 423632700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com