Provider Demographics
NPI:1568571768
Name:WISE, SUSANNAH S (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:S
Last Name:WISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:SUITE 4100
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-7920
Practice Address - Fax:732-235-7079
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-08-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMA074927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9031901Medicaid
NJ066925NAHMedicare PIN
H77926Medicare UPIN
NJ066925A00Medicare PIN