1417042623 NPI number — JOHN E. WISE MD PA

Table of content: (NPI 1417042623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417042623 NPI number — JOHN E. WISE MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN E. WISE MD PA
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:
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:
1417042623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 13TH AVE NE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
HICKORY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28601-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-328-2094
Provider Business Mailing Address Fax Number:
828-328-8980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 13TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
HICKORY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28601-3700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-328-2094
Provider Business Practice Location Address Fax Number:
828-328-8980
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WISE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
EDNEY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-328-2094

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  11979 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8988634 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 88634 . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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