MEDICARE: ROBERT MARSHALL WILD JR. 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	208800000X	Urology Physician	MD019167E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528047024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT MARSHALL WILD JR. M.D.

Provider Business Mailing Address
First Line	:	905 UNIVERSITY DR
Second Line	:
City	:	STATE COLLEGE
State	:	PA
Zip	:	16801-6626
Country	:	US
Telephone Number	:	814-238-8418
Fax Number	:	814-234-2888

Provider Business Practice Location Address
First Line	:	905 UNIVERSITY DR
Second Line	:
City	:	STATE COLLEGE
State	:	PA
Zip	:	16801-6626
Country	:	US
Telephone Number	:	814-238-8418
Fax Number	:	814-234-2888

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	08/03/2010

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