Provider Demographics
NPI:1417908385
Name:WISE, MARC S (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:S
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-2584
Practice Address - Country:US
Practice Address - Phone:513-312-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085676207P00000X
NE26113207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000481153OtherBCBS FAIRFIELD
OH000000375342OtherBCBS MEMORIAL
OH000000375345OtherBCBS CIRCLEVILLE
OH000000487936OtherBCBS MIDDLETOWN
OH2603552Medicaid
OHP00297323Medicare PIN
OHWI4170141Medicare PIN
WI4170142Medicare PIN
OH000000375345OtherBCBS CIRCLEVILLE
WI4170144Medicare PIN
I42862Medicare UPIN
OHP00333486Medicare PIN
WI4170143Medicare PIN