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General NPI Number Information
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NPI Number | 1972573442
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Entity Type | Individual
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Provider Name | LOREN M WISE MD
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Gender | Female
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Dates
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Enumeration Date | 01/25/2006
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Last Update Date | 10/10/2014
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Provider Practice Location Address
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Address Line | 5629 STADIUM DR SUITE D
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City | KALAMAZOO
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State | MI
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Zip | 49009-1952
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Country | US
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Telephone | 269-372-5701
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Fax | 269-372-5702
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Provider Business Mailing Address
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Address Line | 601 JOHN ST BOX 42
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City | KALAMAZOO
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State | MI
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Zip | 49007-5341
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Country | US
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Telephone | 269-372-5701
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Fax | 269-372-5702
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 4301078298
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License Number State | MI
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