MEDICARE: HENRY E WILEY III MD PA

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	207ND0900X	Dermatopathology Physician

General Provider Information

NPI Number	:	1154519767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENRY E WILEY III MD PA

Provider Business Mailing Address
First Line	:	1425 S HOWARD AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-3126
Country	:	US
Telephone Number	:	813-253-2635
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 S HOWARD AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-3126
Country	:	US
Telephone Number	:	813-253-2635
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HENRY E WILEY III
Credential	:	MD
Telephone Number	:	813-253-2635

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	11/06/2007

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