Healthcare Provider Details

I. General information

NPI: 1548866791
Provider Name (Legal Business Name): ROBERT WILLIAM WISENBERGER JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

IV. Provider business mailing address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number434436
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number434436
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.434436
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: