Healthcare Provider Details

I. General information

NPI: 1962586974
Provider Name (Legal Business Name): WYTHE GASTROENTERLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 W RIDGE RD SUITE E
WYTHEVILLE VA
24382-1094
US

IV. Provider business mailing address

590 W RIDGE RD SUITE E
WYTHEVILLE VA
24382-1094
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-2383
  • Fax: 276-228-5829
Mailing address:
  • Phone: 276-228-2383
  • Fax: 276-228-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: BETH TAYLOR
Title or Position: PRESIDENT
Credential: MD
Phone: 276-228-2383