Provider Demographics
NPI:1093861890
Name:WISE, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WISE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PAGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-3531
Mailing Address - Country:US
Mailing Address - Phone:603-752-2200
Mailing Address - Fax:
Practice Address - Street 1:59 PAGE HILL RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NH
Practice Address - Zip Code:03570-3531
Practice Address - Country:US
Practice Address - Phone:603-752-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO3702207P00000X
NH9894207Q00000X, 207P00000X
NY183910207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHAA25502OtherHARVARD PILGRIM
NHRE5767Medicare PIN
NHF21079Medicare UPIN