Provider Demographics
NPI:1104204718
Name:WISEMEN CLINICAL RESEARCH GROUP, LLC
Entity Type:Organization
Organization Name:WISEMEN CLINICAL RESEARCH GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTHONETTE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WAAJID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-474-1224
Mailing Address - Street 1:3300 MEMORIAL DR
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2700
Mailing Address - Country:US
Mailing Address - Phone:404-474-1224
Mailing Address - Fax:404-891-0391
Practice Address - Street 1:3300 MEMORIAL DR
Practice Address - Street 2:SUITE D-1
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2700
Practice Address - Country:US
Practice Address - Phone:404-474-1224
Practice Address - Fax:404-891-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch