Provider Demographics
NPI:1639543374
Name:ALLEY, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4267 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1519
Mailing Address - Country:US
Mailing Address - Phone:313-236-2881
Mailing Address - Fax:
Practice Address - Street 1:4267 MONROE ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1519
Practice Address - Country:US
Practice Address - Phone:313-236-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN121773384146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0091158406OtherBLUE CROSS COMPLETE