Healthcare Provider Details

I. General information

NPI: 1205835683
Provider Name (Legal Business Name): WILLIAM CRAIG TYREE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 TRISTA LN
GLASGOW KY
42141-3482
US

IV. Provider business mailing address

PO BOX 416
GLASGOW KY
42142-0416
US

V. Phone/Fax

Practice location:
  • Phone: 270-659-0184
  • Fax: 270-651-9264
Mailing address:
  • Phone: 270-659-0184
  • Fax: 270-651-9264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number34721
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: