Provider Demographics
NPI:1043205586
Name:WISE, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WISE
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 1:1006 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3219
Mailing Address - Country:US
Mailing Address - Phone:406-586-8711
Mailing Address - Fax:406-587-2602
Practice Address - Street 1:1006 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3219
Practice Address - Country:US
Practice Address - Phone:406-586-8711
Practice Address - Fax:406-587-2602
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT930037579OtherRAILROAD MEDICARE
MT930037579OtherRAILROAD MEDICARE
MTD96160Medicare UPIN
MT010001104Medicare ID - Type Unspecified