Provider Demographics
NPI:1154416717
Name:HEALTHWISE MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:HEALTHWISE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:989-358-8100
Mailing Address - Street 1:101 OXBOW DRIVE
Mailing Address - Street 2:1
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707
Mailing Address - Country:US
Mailing Address - Phone:989-358-8100
Mailing Address - Fax:989-354-4979
Practice Address - Street 1:101 OXBOW DRIVE
Practice Address - Street 2:HEALTHWISE MEDICAL CLINIC
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-358-8100
Practice Address - Fax:989-354-4979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704177958363LF0000X
MI4704208256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4975205Medicaid
MI49775199Medicaid
500Z410370OtherBCBS
MIS77230Medicare UPIN
MI49775199Medicaid
MIP37540002Medicare PIN
MI4975205Medicaid