Provider Demographics
NPI:1417042623
Name:JOHN E. WISE MD PA
Entity Type:Organization
Organization Name:JOHN E. WISE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDNEY
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-328-2094
Mailing Address - Street 1:11 13TH AVE NE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3700
Mailing Address - Country:US
Mailing Address - Phone:828-328-2094
Mailing Address - Fax:828-328-8980
Practice Address - Street 1:11 13TH AVE NE
Practice Address - Street 2:SUITE 103
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3700
Practice Address - Country:US
Practice Address - Phone:828-328-2094
Practice Address - Fax:828-328-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11979173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988634Medicaid
NC88634OtherBLUE CROSS BLUE SHIELD NC
NC8988634Medicaid
NC201112Medicare PIN