Healthcare Provider Details

I. General information

NPI: 1780649780
Provider Name (Legal Business Name): BENJAMIN W WILEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 EXECUTIVE DR STE 101
HIXSON TN
37343-7900
US

IV. Provider business mailing address

4976 ALPHA LN
HIXSON TN
37343-5470
US

V. Phone/Fax

Practice location:
  • Phone: 423-874-0125
  • Fax: 423-874-0154
Mailing address:
  • Phone: 423-497-5355
  • Fax: 423-308-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35989
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: