Healthcare Provider Details

I. General information

NPI: 1538133848
Provider Name (Legal Business Name): ROBERT J WYLIE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5078 HIGH DR
LAKESIDE AZ
85929-5551
US

IV. Provider business mailing address

PO BOX 2170
LAKESIDE AZ
85929-2170
US

V. Phone/Fax

Practice location:
  • Phone: 928-242-1162
  • Fax: 928-368-9080
Mailing address:
  • Phone: 928-242-1162
  • Fax: 928-368-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number18644A
License Number StateAZ

VIII. Authorized Official

Name: DR. ROBERT J WYLIE
Title or Position: OWNER
Credential: MD
Phone: 928-242-1162