Provider Demographics
NPI:1508856832
Name:WISELY, LORI M (MD)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:M
Last Name:WISELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 S MAIN ST;
Practice Address - Street 2:SUITE 4
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-8327
Practice Address - Country:US
Practice Address - Phone:765-675-2069
Practice Address - Fax:765-675-7327
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042996A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200106590AMedicaid
IN200106590Medicaid
IN200106590Medicaid
IN200106590AMedicaid
IN811060Medicare ID - Type Unspecified
G29772Medicare UPIN