Basic Information
| Provider Information | |||||||||
| NPI: | 1184624371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISDOM | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 N BEDFORD RD | ||||||||
| Address2: | CAREMOUNT MEDICAL, PC | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142327588 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 BEDFORD RD | ||||||||
| Address2: | CAREMOUNT MEDICAL, PC | ||||||||
| City: | KATONAH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105362115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142327588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 201012 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 01873656 | 05 | NY | MEDICAID |