Provider Demographics
NPI:1811960214
Name:WISE, RONALD S (MD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:S
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1055 RIBAUT RD
Mailing Address - Street 2:STE 30
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5447
Mailing Address - Country:US
Mailing Address - Phone:843-524-8171
Mailing Address - Fax:843-525-6613
Practice Address - Street 1:1055 RIBAUT RD
Practice Address - Street 2:STE 30
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5447
Practice Address - Country:US
Practice Address - Phone:843-524-8171
Practice Address - Fax:843-525-6613
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC4722208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC020047288OtherRAILROAD MEDICARE
SC047229Medicaid
SC020047288OtherRAILROAD MEDICARE
SCC605212995Medicare ID - Type Unspecified