Provider Demographics
NPI:1740319904
Name:WISE, JAIME CHRISTINE (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:CHRISTINE
Last Name:WISE
Suffix:
Gender:F
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:PO BOX 848886
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8886
Mailing Address - Country:US
Mailing Address - Phone:904-446-3451
Mailing Address - Fax:888-507-9833
Practice Address - Street 1:800 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2202
Practice Address - Country:US
Practice Address - Phone:803-286-1214
Practice Address - Fax:888-507-9833
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00306207Q00000X
SCMMD.36408MD207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1055Medicaid
SCNC1055Medicaid
SCNC1055Medicaid
NCNC3697BMedicare PIN