Healthcare Provider Details

I. General information

NPI: 1497770390
Provider Name (Legal Business Name): WISE COUNTY MEDICAL & SURGICAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 13TH ST
BRIDGEPORT TX
76426-2454
US

IV. Provider business mailing address

1306 13TH ST
BRIDGEPORT TX
76426-2454
US

V. Phone/Fax

Practice location:
  • Phone: 940-627-7443
  • Fax: 940-627-7597
Mailing address:
  • Phone: 940-627-7443
  • Fax: 940-627-7597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KALA C WALSH
Title or Position: ADMINISTRATOR
Credential:
Phone: 940-627-7829