Provider Demographics
NPI:1164597597
Name:WILLIAM J WISE MD SC
Entity Type:Organization
Organization Name:WILLIAM J WISE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-352-3849
Mailing Address - Street 1:320 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2179
Mailing Address - Country:US
Mailing Address - Phone:708-447-2238
Mailing Address - Fax:708-447-2264
Practice Address - Street 1:7729 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534
Practice Address - Country:US
Practice Address - Phone:708-447-2238
Practice Address - Fax:708-447-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X, 208D00000X
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
673330Medicare ID - Type Unspecified