Healthcare Provider Details

I. General information

NPI: 1568436871
Provider Name (Legal Business Name): ROBERT J WYLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941-0860
US

IV. Provider business mailing address

PO BOX 860
WHITERIVER AZ
85941-0860
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-4911
  • Fax: 928-338-5508
Mailing address:
  • Phone: 928-338-4911
  • Fax: 928-338-5508

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:
Title or Position:
Credential:
Phone: