MEDICARE: DYLAN MICHAEL CARLISLE

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	213E00000X	Podiatrist	POD001391	GA

General Provider Information

NPI Number	:	1518426295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN MICHAEL CARLISLE

Provider Business Mailing Address
First Line	:	211 E BUTLER RD
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2169
Country	:	US
Telephone Number	:	505-328-5538
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 E BUTLER RD
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2169
Country	:	US
Telephone Number	:	864-281-9171
Fax Number	:

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

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	06/28/2019

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Directions to “ DYLAN MICHAEL CARLISLE ” Practice Location

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