Provider Demographics
NPI:1568436871
Name:WYLIE, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WYLIE
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 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-5508
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-5508
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18644A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
241333500OtherOWCP
AZ1629236716Medicaid
AZ286254Medicaid
AZ1780614008Medicaid
AZAZ0342850OtherBLUE CROSS BLUE SHIELD AZ
AZ1871523191Medicaid
AZ1295993376Medicaid
AZ1629236716Medicaid
ZMD18644Medicare ID - Type Unspecified