Provider Demographics
NPI:1407989932
Name:EMLEY, TYLER E (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:E
Last Name:EMLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1104 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3211
Practice Address - Country:US
Practice Address - Phone:219-866-5141
Practice Address - Fax:219-866-3234
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060040A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200860790AMedicaid
0091108094OtherBLUE SHIELD OFILLINOIS
0091108094OtherBLUE SHIELD OFILLINOIS