Healthcare Provider Details

I. General information

NPI: 1164601746
Provider Name (Legal Business Name): RICHARD G WISE DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SYCAMORE DRIVE
NEW MIDDLETOWN OH
44442
US

IV. Provider business mailing address

PO BOX 272
NEW MIDDLETOWN OH
44442-0272
US

V. Phone/Fax

Practice location:
  • Phone: 330-542-2881
  • Fax: 330-542-0074
Mailing address:
  • Phone: 330-542-2881
  • Fax: 330-542-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number34003728
License Number StateOH

VIII. Authorized Official

Name: RICHARD G WISE
Title or Position: PRESIDENT
Credential: D.O.
Phone: 330-542-2881