Healthcare Provider Details

I. General information

NPI: 1124046040
Provider Name (Legal Business Name): JOSEPH A. WYLLIE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 SOUTH COUNTY TRAIL
EAST GREENWICH RI
02818
US

IV. Provider business mailing address

1377 SOUTH COUNTY TRAIL
EAST GREENWICH RI
02818
US

V. Phone/Fax

Practice location:
  • Phone: 401-226-7590
  • Fax: 401-886-7571
Mailing address:
  • Phone: 401-226-7590
  • Fax: 401-886-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDO00420
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: