=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356090534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADAM WISE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2022
-----------------------------------------------------
Last Update Date | 06/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3249 OAK PARK AVE
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60402-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-438-8789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 WASHINGTON BLVD APT 1I
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60302-4165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-438-8789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 125080835
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------