Provider Demographics
NPI:1538133848
Name:ROBERT J WYLIE MD PC
Entity Type:Organization
Organization Name:ROBERT J WYLIE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-242-1162
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-2170
Mailing Address - Country:US
Mailing Address - Phone:928-242-1162
Mailing Address - Fax:928-368-9080
Practice Address - Street 1:5078 HIGH DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5551
Practice Address - Country:US
Practice Address - Phone:928-242-1162
Practice Address - Fax:928-368-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18644A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286254Medicaid
AZAZ0342850OtherBLUE CROSS BLUE SHIELD
241333500OtherOWCP
AZAZ0342850OtherBLUE CROSS BLUE SHIELD
E23959Medicare UPIN