Healthcare Provider Details

I. General information

NPI: 1912973736
Provider Name (Legal Business Name): GREGORY A. WISEMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 N LINCOLN ST
GREENSBURG IN
47240-1327
US

IV. Provider business mailing address

712 N LINCOLN ST
GREENSBURG IN
47240-1327
US

V. Phone/Fax

Practice location:
  • Phone: 812-663-8079
  • Fax: 812-663-9298
Mailing address:
  • Phone: 812-663-8079
  • Fax: 812-663-9298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01025482
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: