Provider Demographics
NPI:1164601746
Name:RICHARD G WISE DO INC
Entity Type:Organization
Organization Name:RICHARD G WISE DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-542-2881
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:NEW MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44442-0272
Mailing Address - Country:US
Mailing Address - Phone:330-542-2881
Mailing Address - Fax:330-542-0074
Practice Address - Street 1:11 SYCAMORE DRIVE
Practice Address - Street 2:
Practice Address - City:NEW MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:44442
Practice Address - Country:US
Practice Address - Phone:330-542-2881
Practice Address - Fax:330-542-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003728261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0598769Medicaid
OHX63202Medicare UPIN
OH0598769Medicaid