MEDICARE: BRIAN KEITH WISE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	41287	CO
2	2084P0800X	Psychiatry Physician	41287	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C811544	OTHER	CO	MEDICARE PTAN
4	C802299	OTHER	CO	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1043211683	OTHER	CO	NPI NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043211683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN KEITH WISE MD

Provider Business Mailing Address
First Line	:	6053 S QUEBEC ST STE 203
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80111-4505
Country	:	US
Telephone Number	:	720-708-4287
Fax Number	:	720-815-2581

Provider Business Practice Location Address
First Line	:	6053 S QUEBEC ST STE 203
Second Line	:
City	:	CENTENNIAL
State	:	CO
Zip	:	80111-4505
Country	:	US
Telephone Number	:	720-708-4287
Fax Number	:	720-815-2581

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	10/04/2024

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Directions to “ BRIAN KEITH WISE MD” Practice Location

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