Provider Demographics
NPI:1497909576
Name:JEUTI B. WYLDE, MD PSC
Entity Type:Organization
Organization Name:JEUTI B. WYLDE, MD PSC
Other - Org Name:JEFFERSONVILLE PSYCHIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEUTI
Authorized Official - Middle Name:B
Authorized Official - Last Name:WYLDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-282-2036
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:OTISCO
Mailing Address - State:IN
Mailing Address - Zip Code:47163-0128
Mailing Address - Country:US
Mailing Address - Phone:812-282-2036
Mailing Address - Fax:812-282-2277
Practice Address - Street 1:1114 E. 10TH ST.
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4227
Practice Address - Country:US
Practice Address - Phone:812-282-2036
Practice Address - Fax:812-282-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-16
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041261A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100362930Medicaid
IN260780Medicare PIN