Provider Demographics
NPI:1215028329
Name:WISE, ROBERT L (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-5115
Mailing Address - Country:US
Mailing Address - Phone:618-244-3370
Mailing Address - Fax:618-244-3395
Practice Address - Street 1:329 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-5115
Practice Address - Country:US
Practice Address - Phone:618-244-3370
Practice Address - Fax:618-244-3395
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8421484OtherBLUE CROSS/BLUE SHIELD
ILU67626Medicare UPIN
IL313620Medicare ID - Type Unspecified