Healthcare Provider Details

I. General information

NPI: 1609177179
Provider Name (Legal Business Name): ROBERT WILLIAM WYLIE BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAROSA RD STE D
LONG BEACH MS
39560
US

IV. Provider business mailing address

1114 HICKORY DR
LONG BEACH MS
39560-3223
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-8050
  • Fax: 228-863-1693
Mailing address:
  • Phone: 228-863-8050
  • Fax: 228-863-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD 0457
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAL 4079
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1080
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: