Basic Information
| Provider Information | |||||||||
| NPI: | 1366419434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISS | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3707 N 7TH ST | ||||||||
| Address2: | #305 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850145059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649100 | ||||||||
| FaxNumber: | 6022649101 | ||||||||
| Practice Location | |||||||||
| Address1: | 5823 W EUGIE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853041276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028431265 | ||||||||
| FaxNumber: | 6028431297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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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 | 207RG0100X | 2029 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 120390 | 01 | AZ | GROUP MEDICARE NUMBER | OTHER | 290445-06 | 05 | AZ | MEDICAID | 290445 02 | 05 | AZ | MEDICAID | 317047 | 01 | AZ | GROUP MEDICAID NUMBER | OTHER |