MEDICARE: DR. GREGORY S WISDOM 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	207Y00000X	Otolaryngology Physician	201012	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184624371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY S WISDOM M.D.

Provider Business Mailing Address
First Line	:	110 N BEDFORD RD
Second Line	:	CAREMOUNT MEDICAL, PC
City	:	MOUNT KISCO
State	:	NY
Zip	:	10549
Country	:	US
Telephone Number	:	914-241-1050
Fax Number	:	914-232-7588

Provider Business Practice Location Address
First Line	:	111 BEDFORD RD
Second Line	:	CAREMOUNT MEDICAL, PC
City	:	KATONAH
State	:	NY
Zip	:	10536-2115
Country	:	US
Telephone Number	:	914-241-1050
Fax Number	:	914-232-7588

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	10/19/2016

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