=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518992528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN FLINT WISE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 01/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 W BLOOMFIELD RD
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-336-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1148
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47402-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-336-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 01033338A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------