MEDICARE: DR. DALE H WYTOCK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	117459	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518960467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE H WYTOCK MD

Provider Business Mailing Address
First Line	:	17501 E 40 HWY
Second Line	:	STE 213A
City	:	INDEPENDENCE
State	:	MO
Zip	:	64055-6445
Country	:	US
Telephone Number	:	816-478-4887
Fax Number	:	816-478-7222

Provider Business Practice Location Address
First Line	:	2521 GLENN HENDREN DR
Second Line	:	STE 408
City	:	LIBERTY
State	:	MO
Zip	:	64068-3388
Country	:	US
Telephone Number	:	816-478-4887
Fax Number	:	816-478-7222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/18/2008

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