Healthcare Provider Details

I. General information

NPI: 1811484272
Provider Name (Legal Business Name): KYLE WYLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 1106
CHICAGO IL
60612-3845
US

IV. Provider business mailing address

409 CANAL COURT NORTH DR APT I
INDIANAPOLIS IN
46202-4641
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 626-590-7901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number036.160715
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: