Basic Information
| Provider Information | |||||||||
| NPI: | 1467652370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISE COUNTY MEDICAL & SURGICAL ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406277443 | ||||||||
| FaxNumber: | 9406277464 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 W EAGLE DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406277443 | ||||||||
| FaxNumber: | 9406277464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9406278982 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 092162902 | 05 | TX | MEDICAID | 092162901 | 05 | TX | MEDICAID | CD5800 | 01 | TX | RAILROAD MEDICARE | OTHER |