Provider Demographics
NPI:1558379495
Name:WISE, MARY BERNADETTE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:WISE
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 1:320 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-352-3849
Mailing Address - Fax:
Practice Address - Street 1:7929 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534
Practice Address - Country:US
Practice Address - Phone:708-447-2238
Practice Address - Fax:708-447-2264
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41438Medicare UPIN
P05688Medicare ID - Type Unspecified