Provider Demographics
NPI:1295763571
Name:WYLIE, WILLIAM LINDSAY JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LINDSAY
Last Name:WYLIE
Suffix:JR
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:9 MILLS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4015
Practice Address - Country:US
Practice Address - Phone:864-242-4840
Practice Address - Fax:864-232-8113
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9847208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4460414OtherAETNA ID
SC098478Medicaid
SC571004971001OtherBCBS OF SC ID
SC1587187OtherCIGNA ID
SCAA24457951Medicare PIN