1457561912 NPI number — JOHN D WYLIE M.D., PH.D.

Table of content: JOHN D WYLIE M.D., PH.D. (NPI 1457561912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457561912 NPI number — JOHN D WYLIE M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYLIE
Provider First Name:
JOHN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457561912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6100 W CREEK RD STE 35
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44131-2133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-986-2915
Provider Business Mailing Address Fax Number:
216-986-2915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6100 W CREEK RD STE 35
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44131-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-986-2915
Provider Business Practice Location Address Fax Number:
216-986-2915
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD34584 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 2010-00700 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NC1532 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5919470 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: H214822 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 114400200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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