Healthcare Provider Details

I. General information

NPI: 1972526200
Provider Name (Legal Business Name): JOHN BRADLEY WYLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RADIOLOGY EGLESTON HOSPITAL 1405 CLIFTON RD NE
ATLANTA GA
30322-0001
US

IV. Provider business mailing address

RADIOLOGY EGLESTON HOSPITAL 1405 CLIFTON RD NE
ATLANTA GA
30322-0001
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-6407
  • Fax: 404-785-1216
Mailing address:
  • Phone: 404-785-6407
  • Fax: 404-785-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26415
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: