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NPI Code Detail

MEDICARE: DR. MERRELL THAMES WISEMAN M.D.

MEDICARE: DR. MERRELL THAMES WISEMAN 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
1208000000XPediatrics PhysicianMD00025137WA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1WI7556OTHERWABLUE SHIELD VM
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3US4590191OTHERWAAETNA SPECIALIST PIN

General Provider Information

NPI Number : 1528175882
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MERRELL THAMES WISEMAN M.D.
Provider Business Mailing Address
First Line : 1810 34TH AVE
Second Line :
City : SEATTLE
State : WA
Zip : 98122-3342
Country : US
Telephone Number : 206-323-3765
Fax Number :
Provider Business Practice Location Address
First Line : 4800 SAND POINT WAY NE
Second Line :
City : SEATTLE
State : WA
Zip : 98105-3901
Country : US
Telephone Number : 206-987-2000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/24/2006
Last Update Date : 08/10/2009

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