Basic Information
| Provider Information | |||||||||
| NPI: | 1194706895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | RALPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9132 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038939784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 HAMBURG TPKE | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074702110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739040404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 05/18/2010 | ||||||||
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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 | 25MA06322000 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8651400 | 05 | MA | MEDICAID |