MEDICARE: DR. TERRENCE WISE MD

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	207R00000X	Internal Medicine Physician	056246	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2106119	OTHER		HIGHMARK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790759579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRENCE WISE MD

Provider Business Mailing Address
First Line	:	1255 HIGHWAY 54 W
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4526
Country	:	US
Telephone Number	:	770-719-5630
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 HIGHWAY 54 W
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4526
Country	:	US
Telephone Number	:	770-719-5630
Fax Number	:

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

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	03/06/2020

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Directions to “ DR. TERRENCE WISE MD” Practice Location

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