MEDICARE: MR. ADOLPH MICHAEL WYCHULIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MD418365	PA

General Provider Information

NPI Number	:	1023001617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADOLPH MICHAEL WYCHULIS MD

Provider Business Mailing Address
First Line	:	24 S MAIN ST
Second Line	:
City	:	SHENANDOAH
State	:	PA
Zip	:	17976-2331
Country	:	US
Telephone Number	:	570-462-1033
Fax Number	:	570-462-1171

Provider Business Practice Location Address
First Line	:	24 S MAIN ST
Second Line	:
City	:	SHENANDOAH
State	:	PA
Zip	:	17976-2331
Country	:	US
Telephone Number	:	570-462-1033
Fax Number	:	570-462-1171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2005
Last Update Date	:	03/18/2008

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