Basic Information
| Provider Information | |||||||||
| NPI: | 1417100157 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISE HEALTH PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 WYNNCREST DR | ||||||||
| Address2: | |||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473229602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4755 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739899868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 11/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | SHEPHALI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8473229602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 036091776 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01637603 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 036091776 | 05 | IL | MEDICAID |