Provider Demographics
NPI:1467640128
Name:MEDWISE HEALTH & DIAGNOSTIC INC.
Entity Type:Organization
Organization Name:MEDWISE HEALTH & DIAGNOSTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:KESHISHIANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-568-0006
Mailing Address - Street 1:501 W GLENOAKS BLVD
Mailing Address - Street 2:432
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2896
Mailing Address - Country:US
Mailing Address - Phone:818-568-0006
Mailing Address - Fax:818-241-3319
Practice Address - Street 1:501 W GLENOAKS BLVD
Practice Address - Street 2:432
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2896
Practice Address - Country:US
Practice Address - Phone:818-568-0006
Practice Address - Fax:818-241-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52415335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52415OtherMEDICAL LICENSE NUMBER