Provider Demographics
NPI:1548552656
Name:WISE PSYCHIATRY, PC
Entity type:Organization
Organization Name:WISE PSYCHIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-708-4287
Mailing Address - Street 1:6053 S QUEBEC ST STE 203
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-4505
Mailing Address - Country:US
Mailing Address - Phone:720-708-4287
Mailing Address - Fax:720-787-9946
Practice Address - Street 1:6053 S QUEBEC ST STE 203
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-4505
Practice Address - Country:US
Practice Address - Phone:720-708-4287
Practice Address - Fax:720-815-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-07
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO412872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70583072Medicaid
CO70583072Medicaid