Healthcare Provider Details

I. General information

NPI: 1750367033
Provider Name (Legal Business Name): BRADFORD BITTNER WYLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7093 DEXTER ANN ARBOR RD
DEXTER MI
48130-8568
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR LBBY J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-426-9028
  • Fax: 734-426-9029
Mailing address:
  • Phone: 734-747-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301067908
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1108127972
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBCBS
# 2
Identifier459558310
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: