MEDICARE: MARK W WYLIE 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	207X00000X	Orthopaedic Surgery Physician	L7265	TX
2	207XS0117X	Orthopaedic Surgery of the Spine Physician	L7265	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00166250	OTHER		RAIL ROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1750306502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK W WYLIE M.D.

Provider Business Mailing Address
First Line	:	6301 HARRIS PKWY STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4249
Country	:	US
Telephone Number	:	817-433-3450
Fax Number	:	817-294-6429

Provider Business Practice Location Address
First Line	:	6301 HARRIS PKWY STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4249
Country	:	US
Telephone Number	:	817-433-3450
Fax Number	:	817-294-6429

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	09/25/2019

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Directions to “ MARK W WYLIE M.D.” Practice Location

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