Provider Demographics
NPI:1578603924
Name:WISE MEDICAL GROUP
Entity Type:Organization
Organization Name:WISE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMULO
Authorized Official - Middle Name:ABRANTES
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1276-395-5983
Mailing Address - Street 1:PO BOX 1734
Mailing Address - Street 2:203 FRONT ST. WEST
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-1734
Mailing Address - Country:US
Mailing Address - Phone:127-639-5598
Mailing Address - Fax:127-639-5598
Practice Address - Street 1:203 FRONT ST WEST
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230
Practice Address - Country:US
Practice Address - Phone:276-395-5983
Practice Address - Fax:276-395-5986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty