Provider Demographics
NPI:1578579686
Name:WISDOM, MICHAEL R (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:WISDOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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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 ST
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
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT000867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA354809OtherWELLCARE
GA58172018531201A001OtherTRICARE
GA980154OtherBCBS
GA354809OtherWELLCARE
GA$$$$$$$$$AMedicare PIN