Healthcare Provider Details

I. General information

NPI: 1366084915
Provider Name (Legal Business Name): TYLER WILLIAM MAHARREY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 13TH ST
JASPER IN
47546-1881
US

IV. Provider business mailing address

998 S STATE ROAD 61
WINSLOW IN
47598-8455
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-7441
  • Fax:
Mailing address:
  • Phone: 812-582-0997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number06005989A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: