Basic Information
| Provider Information | |||||||||
| NPI: | 1689667180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | W | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4520 UNION DEPOSIT RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176526105 | ||||||||
| FaxNumber: | 7176522165 | ||||||||
| Practice Location | |||||||||
| Address1: | 4518 UNION DEPOSIT RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176525840 | ||||||||
| FaxNumber: | 7176528152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 09/11/2013 | ||||||||
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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 | 2085R0202X | MD055460L | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1689667180026 | 05 | PA | MEDICAID | 16896671800022 | 05 | PA | MEDICAID | 16896671800009 | 05 | PA | MEDICAID | 1689667180024 | 05 | PA | MEDICAID | 0015263770007 | 05 | PA | MEDICAID | 300107022 | 01 | PA | RAILROAD MEDICARE | OTHER | 16896671800027 | 05 | PA | MEDICAID |