MEDICARE: DR. MATTHEW DAVID 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	2080P0205X	Pediatric Endocrinology Physician	57356	MN

General Provider Information

NPI Number	:	1295944932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW DAVID WISE MD

Provider Business Mailing Address
First Line	:	3800 PARK NICOLLET BLVD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2527
Country	:	US
Telephone Number	:	952-993-1792
Fax Number	:	952-993-1761

Provider Business Practice Location Address
First Line	:	3800 PARK NICOLLET BLVD
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-2527
Country	:	US
Telephone Number	:	952-993-1792
Fax Number	:	952-993-1761

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	12/06/2013

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