Healthcare Provider Details

I. General information

NPI: 1144649856
Provider Name (Legal Business Name): TYLER WISHAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY STE 420
MOUNT VERNON IL
62864-2478
US

IV. Provider business mailing address

PO BOX 955860
SAINT LOUIS MO
63195-2588
US

V. Phone/Fax

Practice location:
  • Phone: 618-899-3900
  • Fax:
Mailing address:
  • Phone: 636-498-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005806
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005806
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: