Healthcare Provider Details

I. General information

NPI: 1184814899
Provider Name (Legal Business Name): ES-HAGH WISEMAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2007
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CARY RD
GREAT NECK NY
11021-1517
US

IV. Provider business mailing address

21 CARY RD
GREAT NECK NY
11021-1517
US

V. Phone/Fax

Practice location:
  • Phone: 516-946-8333
  • Fax:
Mailing address:
  • Phone: 516-946-8333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number137450
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0158541
License Number StateNY

VIII. Authorized Official

Name: DR. ES-HAGH WISEMAN
Title or Position: DOCTOR
Credential: MD PC
Phone: 718-268-7246