Basic Information
| Provider Information | |||||||||
| NPI: | 1336330869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9700 N 91ST ST | ||||||||
| Address2: | SUITE C-200 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852585054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804255000 | ||||||||
| FaxNumber: | 4804255010 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 N SCOTTSDALE RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852515648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804255000 | ||||||||
| FaxNumber: | 4804255010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 07/03/2012 | ||||||||
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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 | 5126120 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 43723 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 621178 | 05 | AZ | MEDICAID |