Provider Demographics
NPI:1437383379
Name:WESLEY D WYLIE MD LLC
Entity Type:Organization
Organization Name:WESLEY D WYLIE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-380-0432
Mailing Address - Street 1:1027 OAKRIDGE RD S
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5615
Mailing Address - Country:US
Mailing Address - Phone:801-380-0432
Mailing Address - Fax:801-802-0108
Practice Address - Street 1:280 RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5764
Practice Address - Country:US
Practice Address - Phone:801-380-0432
Practice Address - Fax:801-802-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187190-1205261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11032Medicaid
UT11032Medicaid
UT005544701Medicare PIN