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General NPI Number Information
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NPI Number | 1578603924
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Entity Type | Organization
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Legal Business Name | WISE MEDICAL GROUP
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 203 FRONT ST WEST
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City | COEBURN
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State | VA
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Zip | 24230
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Country | US
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Telephone | 276-395-5983
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Fax | 276-395-5986
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Provider Business Mailing Address
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Address Line | PO BOX 1734 203 FRONT ST. WEST
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City | COEBURN
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State | VA
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Zip | 24230-1734
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Country | US
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Telephone | 127-639-5598
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Fax | 127-639-5598
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. ROMULO ABRANTES FAJARDO
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Credential | MD
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Telephone | 12763955983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0101221509
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License Number State | VA
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