Provider Demographics
NPI:1689667180
Name:WISE, SCOTT W (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2910
Mailing Address - Country:US
Mailing Address - Phone:717-652-6105
Mailing Address - Fax:717-652-2165
Practice Address - Street 1:4518 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2921
Practice Address - Country:US
Practice Address - Phone:717-652-5840
Practice Address - Fax:717-652-8152
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055460L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1689667180026Medicaid
PA16896671800022Medicaid
PA16896671800009Medicaid
PA1689667180024Medicaid
PA0015263770007Medicaid
PA300107022OtherRAILROAD MEDICARE
PA16896671800027Medicaid
PAG08345Medicare UPIN
PA0015263770007Medicaid
PA783341FJDMedicare PIN
PA16896671800027Medicaid
PA783341EF4Medicare PIN
PA16896671800009Medicaid
PA783341PQLMedicare PIN