Provider Demographics
NPI:1922089192
Name:WISE, MERRILL S III (MD)
Entity Type:Individual
Prefix:DR
First Name:MERRILL
Middle Name:S
Last Name:WISE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5050 POPLAR AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38157-0101
Mailing Address - Country:US
Mailing Address - Phone:901-276-2662
Mailing Address - Fax:
Practice Address - Street 1:5050 POPLAR AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38157-0101
Practice Address - Country:US
Practice Address - Phone:901-276-2662
Practice Address - Fax:901-274-2033
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN411442080S0012X, 207RS0012X, 2084N0402X
TXG9903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117214001Medicaid
86960KMedicare ID - Type Unspecified
TN3822490Medicare PIN
E86206Medicare UPIN