Provider Demographics
NPI:1720043755
Name:WILEY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILEY
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 1:305 HOSPITAL DR
Mailing Address - Street 2:SUITE 305 TATE CENTER
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5805
Mailing Address - Country:US
Mailing Address - Phone:410-768-3701
Mailing Address - Fax:410-766-0881
Practice Address - Street 1:305 HOSPITAL DR
Practice Address - Street 2:SUITE 305 TATE CENTER
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5805
Practice Address - Country:US
Practice Address - Phone:410-768-3701
Practice Address - Fax:410-766-0881
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042388207RP1001X
MDD42388207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD54427404OtherBCBS MD RENDERING
0003OtherBCBS DC RENDERING
MDF07012Medicare UPIN
405L016CMedicare PIN