Basic Information
| Provider Information | |||||||||
| NPI: | 1427105394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISE | ||||||||
| FirstName: | MARSHALL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 US HIGHWAY 27 N | ||||||||
| Address2: | |||||||||
| City: | CYNTHIANA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410313718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592348852 | ||||||||
| FaxNumber: | 8592348859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 41014 | KY | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | K050922 | 01 | KY | MEDICARE PTAN | OTHER | K050921 | 01 | KY | MEDICARE PTAN | OTHER | 7100021390 | 05 | KY | MEDICAID | 0089205 | 05 | OH | MEDICAID |