MEDICARE: DR. KELITA WILEY 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	2084P0800X	Psychiatry Physician	062631	GA

General Provider Information

NPI Number	:	1336358050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELITA WILEY M.D.

Provider Business Mailing Address
First Line	:	5260 SAVANNAH TER
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-2258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 MADISON AVE
Second Line	:	SUITE C50
City	:	MEMPHIS
State	:	TN
Zip	:	38103-3438
Country	:	US
Telephone Number	:	901-465-3203
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/30/2010

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