| Doctor Name: | MARY BERNADETTE WISE |
| NPI Number: | 1558379495 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MD |
| License Number: | |
| Business Practice Address: | 7929 Ogden Ave Lyons, IL - 60534 |
| Business Phone Number: | 7084472238 |
| Business Fax Number: | 7084472264 |
| Mailing Address: | 320 Sunset Ave, LA GRANGE |
| State: | IL |
| Postal Code: | 60525 |
| Phone Number: | 7083523849 |
| Fax Number: | |
| NPI Enumeration Date: | 08/04/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |