Provider Demographics
NPI:1124488630
Name:DR JOHN M WISE
Entity type:Organization
Organization Name:DR JOHN M WISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBICHAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-897-5121
Mailing Address - Street 1:2820 NAPOLEON AVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-6969
Mailing Address - Country:US
Mailing Address - Phone:504-897-5121
Mailing Address - Fax:504-897-9743
Practice Address - Street 1:2820 NAPOLEON AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6969
Practice Address - Country:US
Practice Address - Phone:504-897-5121
Practice Address - Fax:504-897-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12877R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1545759Medicaid
LAG82806Medicare UPIN
LA5E111Medicare PIN