Healthcare Provider Details

I. General information

NPI: 1750348371
Provider Name (Legal Business Name): MIKE O TYLER JR. MD,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9565 HIGHWAY 78 BLDG 100
LADSON SC
29456-4118
US

IV. Provider business mailing address

9565 HIGHWAY 78 BLDG 100
LADSON SC
29456-4118
US

V. Phone/Fax

Practice location:
  • Phone: 843-553-7615
  • Fax: 843-553-1008
Mailing address:
  • Phone: 843-553-7615
  • Fax: 843-553-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number8587
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: