MEDICARE: DR. VANCE ERIC WISE M.D.

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	2085R0202X	Diagnostic Radiology Physician	BP20043790	TX

General Provider Information

NPI Number	:	1114214384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VANCE ERIC WISE M.D.

Provider Business Mailing Address
First Line	:	6431 FANNIN ST
Second Line	:	SUITE MSB 2.130B
City	:	HOUSTON
State	:	TX
Zip	:	77030-5389
Country	:	US
Telephone Number	:	713-704-1478
Fax Number	:	713-704-1715

Provider Business Practice Location Address
First Line	:	6431 FANNIN ST
Second Line	:	SUITE MSB 2.130B
City	:	HOUSTON
State	:	TX
Zip	:	77030-5389
Country	:	US
Telephone Number	:	713-704-1478
Fax Number	:	713-704-1715

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

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	06/08/2016

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