Healthcare Provider Details

I. General information

NPI: 1316435928
Provider Name (Legal Business Name): KYLE J WESLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 06/07/2022
Certification Date: 05/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

615 N MICHIGAN ST
SOUTH BEND IN
46601-1033
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-7458
  • Fax:
Mailing address:
  • Phone: 248-410-4976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5315091412
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02006637A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: