Healthcare Provider Details

I. General information

NPI: 1225247877
Provider Name (Legal Business Name): TYLER J. PROUTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 MEDICAL PARK DR STE 205
BRIDGEPORT WV
26330-9009
US

IV. Provider business mailing address

527 MEDICAL PARK DR STE 204
BRIDGEPORT WV
26330-9009
US

V. Phone/Fax

Practice location:
  • Phone: 304-933-3800
  • Fax: 304-933-3815
Mailing address:
  • Phone: 304-933-3800
  • Fax: 304-933-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number22435
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: