Healthcare Provider Details

I. General information

NPI: 1740840024
Provider Name (Legal Business Name): TYLER BUCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 HENRY ST
GREENSBORO NC
27405-3633
US

IV. Provider business mailing address

169 ASHLEY AVE, ROOM 202 MAIN HOSPITAL MSC333
CHARLESTON SC
29425
US

V. Phone/Fax

Practice location:
  • Phone: 336-663-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberLL82831
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number202401260
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: