Provider Demographics
NPI:1467466367
Name:MICHAEL R WISDOM PT PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:MICHAEL R WISDOM PT PHYSICAL THERAPY INC
Other - Org Name:WISDOM PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:478-746-5469
Mailing Address - Street 1:630 ORANGE ST
Mailing Address - Street 2:WISDOM PHYSICAL THERAPY
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-746-5469
Mailing Address - Fax:478-750-7841
Practice Address - Street 1:630 ORANGE S
Practice Address - Street 2:WISDOM PHYSICAL THERAPY
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-746-5469
Practice Address - Fax:478-750-7841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT000867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA980154OtherBLUE CROSS BLUE SHIELD
=========31201A001OtherPALMETTO TRICARE
R61534Medicare UPIN