Provider Demographics
NPI:1033586060
Name:SAMOGE-WISMER, MARY (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SAMOGE-WISMER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3054 MANCINI TER
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-3311
Mailing Address - Country:US
Mailing Address - Phone:941-916-0340
Mailing Address - Fax:
Practice Address - Street 1:18480 COCHRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-3379
Practice Address - Country:US
Practice Address - Phone:941-743-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT9256314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility