Provider Demographics
NPI:1124124086
Name:WISE, PHILLIP GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GREGORY
Last Name:WISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:SUITE 3300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:616-459-0044
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-01-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301078939208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5217870Medicaid
MI5217870Medicaid
MIC23685Medicare UPIN
MI382285194OtherTAX ID