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General NPI Number Information
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NPI Number | 1427006253
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Entity Type | Organization
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Legal Business Name | MEDWISE PC
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 03/07/2013
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Provider Practice Location Address
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Address Line | 790 GAIL GARDNER WAY
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City | PRESCOTT
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State | AZ
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Zip | 86305-2337
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Country | US
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Telephone | 928-776-9900
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Fax | 928-776-1444
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Provider Business Mailing Address
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Address Line | 790 GAIL GARDNER WAY
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City | PRESCOTT
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State | AZ
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Zip | 86305-2337
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Country | US
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Telephone | 928-776-9900
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Fax | 928-776-1444
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | TED WICKSTROM
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Credential | MD
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Telephone | 928-776-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 21726
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License Number State | AZ
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