Healthcare Provider Details

I. General information

NPI: 1508835703
Provider Name (Legal Business Name): MARC WISH M.D., FACC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 11/27/2023
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 HAMAKER CT SUITE 101
FAIRFAX VA
22031-2238
US

IV. Provider business mailing address

3020 HAMAKER CT SUITE 101
FAIRFAX VA
22031-2238
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-9400
  • Fax: 703-289-9404
Mailing address:
  • Phone: 703-289-9400
  • Fax: 703-289-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number0101034890
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: