Healthcare Provider Details

I. General information

NPI: 1124124086
Provider Name (Legal Business Name): PHILLIP GREGORY WISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE SUITE 3300
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

20952 E 12 MILE RD STE 200
SAINT CLAIR SHORES MI
48081-3203
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-4171
  • Fax: 616-459-0044
Mailing address:
  • Phone: 586-771-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301078939
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: