Healthcare Provider Details

I. General information

NPI: 1306367396
Provider Name (Legal Business Name): TYLER JAMES WILLENBRINK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 COAL VALLEY RD STE 360
CLAIRTON PA
15025-3739
US

IV. Provider business mailing address

575 COAL VALLEY RD STE 360
CLAIRTON PA
15025-3739
US

V. Phone/Fax

Practice location:
  • Phone: 412-466-9400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberLL51189
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD473646
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: