MEDICARE: DR. TYLER JAMES WILLENBRINK M.D.

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	207N00000X	Dermatology Physician	LL51189	SC
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207ND0101X	MOHS-Micrographic Surgery Physician	MD473646	PA

General Provider Information

NPI Number	:	1306367396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYLER JAMES WILLENBRINK M.D.

Provider Business Mailing Address
First Line	:	575 COAL VALLEY RD STE 360
Second Line	:
City	:	CLAIRTON
State	:	PA
Zip	:	15025-3739
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	575 COAL VALLEY RD STE 360
Second Line	:
City	:	CLAIRTON
State	:	PA
Zip	:	15025-3739
Country	:	US
Telephone Number	:	412-466-9400
Fax Number	:

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

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	06/18/2021

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