Provider Demographics
NPI:1427006253
Name:MEDWISE PC
Entity Type:Organization
Organization Name:MEDWISE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-776-9900
Mailing Address - Street 1:790 GAIL GARDNER WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2337
Mailing Address - Country:US
Mailing Address - Phone:928-776-9900
Mailing Address - Fax:928-776-1444
Practice Address - Street 1:790 GAIL GARDNER WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-2337
Practice Address - Country:US
Practice Address - Phone:928-776-9900
Practice Address - Fax:928-776-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ217262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ90503Medicare PIN