Provider Demographics
NPI:1447064175
Name:MEDWISE LLC
Entity type:Organization
Organization Name:MEDWISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:BLACKSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-605-6582
Mailing Address - Street 1:12902 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-6712
Mailing Address - Country:US
Mailing Address - Phone:918-994-3476
Mailing Address - Fax:
Practice Address - Street 1:110 E 41ST ST
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-3851
Practice Address - Country:US
Practice Address - Phone:918-727-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDWISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care