Provider Demographics
| NPI: | 1679719801 |
|---|---|
| Name: | WISE CLINICAL CARE ASSOCIATES |
| Entity type: | Organization |
| Organization Name: | WISE CLINICAL CARE ASSOCIATES |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CFO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | BRIAN |
| Authorized Official - Middle Name: | TODD |
| Authorized Official - Last Name: | SCOGGINS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 940-626-1228 |
| Mailing Address - Street 1: | PO BOX 2078 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DECATUR |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 76234-6156 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 940-683-2338 |
| Mailing Address - Fax: | 940-683-2394 |
| Practice Address - Street 1: | 2202 US HIGHWAY 380 STE 112 |
| Practice Address - Street 2: | |
| Practice Address - City: | BRIDGEPORT |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 76426-2177 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 940-683-2338 |
| Practice Address - Fax: | 940-683-2394 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2008-12-17 |
| Last Update Date: | 2023-01-24 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 207PE0005X | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TX | 206106102 | Other | MEDICAID TEXAS HEALTH STEPS |
| TX | 0047SH | Other | BCBS |
| TX | 206106101 | Medicaid | |
| TX | DP6508 | Other | MEDICARE RAILROAD |
| TX | 206106102 | Other | MEDICAID TEXAS HEALTH STEPS |
