Basic Information
| Provider Information | |||||||||
| NPI: | 1235469974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISEMAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638100 | ||||||||
| FaxNumber: | 6077638048 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HARRISON ST STE 455 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077638100 | ||||||||
| FaxNumber: | 6077638048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2009 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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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 | 208600000X | 190990 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 190990 | NY | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01236451 | 05 | NY | MEDICAID |