Basic Information
| Provider Information | |||||||||
| NPI: | 1891100954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR STE J2000 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347476766 | ||||||||
| FaxNumber: | 7342223100 | ||||||||
| Practice Location | |||||||||
| Address1: | 49650 CHERRY HILL RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481874859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343987899 | ||||||||
| FaxNumber: | 7343987895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0102205010 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 5101025665 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1891100954 | 05 | VA | MEDICAID |