Healthcare Provider Details

I. General information

NPI: 1326035635
Provider Name (Legal Business Name): ROBERT L WYENANDT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-8074
  • Fax: 859-301-4945
Mailing address:
  • Phone: 859-301-8074
  • Fax: 859-301-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30652
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number30652
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: