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General NPI Number Information
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NPI Number | 1124216718
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Entity Type | Organization
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Legal Business Name | JEFFREY B. WISE, M.D., L.L.C.
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 1680 ROUTE 23 SUITE 100
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City | WAYNE
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State | NJ
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Zip | 07470-7501
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Country | US
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Telephone | 973-305-1400
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Fax | 973-694-5580
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Provider Business Mailing Address
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Address Line | 1680 ROUTE 23 SUITE 100
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City | WAYNE
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State | NJ
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Zip | 07470-7501
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Country | US
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Telephone | 973-305-1400
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Fax | 973-694-5580
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JEFFREY BRUCE WISE
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Credential | M.D.
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Telephone | 973-305-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 25M08257300
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License Number State | NJ
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