Provider Demographics
NPI:1639354665
Name:DREW H WYRICK MD PA
Entity Type:Organization
Organization Name:DREW H WYRICK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:H
Authorized Official - Last Name:WYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-747-3910
Mailing Address - Street 1:PO BOX 132890
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-2890
Mailing Address - Country:US
Mailing Address - Phone:903-747-3910
Mailing Address - Fax:903-617-6662
Practice Address - Street 1:1310 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2119
Practice Address - Country:US
Practice Address - Phone:903-747-3910
Practice Address - Fax:903-617-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX267006Medicare PIN