MEDICARE: DANIEL THOMAS WISE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	C004959	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	192539	OTHER	MD	COVENTRY HEALTH INSURANCE
2	LY34	OTHER	MD	CAREFIRST-BLUE CROSS
3	R130	OTHER	MD	FEDERAL-CAREFIRST

General Provider Information

NPI Number	:	1700903390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL THOMAS WISE D.C.

Provider Business Mailing Address
First Line	:	PO BOX 38
Second Line	:	14307 JARRETTSVILLE PIKE
City	:	PHOENIX
State	:	MD
Zip	:	21131-0038
Country	:	US
Telephone Number	:	410-592-7300
Fax Number	:	410-666-0348

Provider Business Practice Location Address
First Line	:	14307 JARRETTSVILLE PIKE
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1763
Country	:	US
Telephone Number	:	410-592-7300
Fax Number	:	410-666-0348

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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