Provider Demographics
NPI:1801018924
Name:GREG A. WISE, M.D., INC.
Entity Type:Organization
Organization Name:GREG A. WISE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-836-2273
Mailing Address - Street 1:4100 VENTURE PL
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9206
Mailing Address - Country:US
Mailing Address - Phone:614-836-2273
Mailing Address - Fax:614-836-9320
Practice Address - Street 1:4100 VENTURE PL
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9206
Practice Address - Country:US
Practice Address - Phone:614-836-2273
Practice Address - Fax:614-836-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH055595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739866Medicaid
OH0739866Medicaid
OH9233241Medicare ID - Type UnspecifiedGROUP NUMBER