=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417410853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER ROGER MARION MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 HARRODSBURG RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-278-9492
-----------------------------------------------------
Fax | 859-469-5461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 YORK ST
-----------------------------------------------------
City | MANITOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54220-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-663-9008
-----------------------------------------------------
Fax | 920-684-1439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 60402
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 60402
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------