Provider Demographics
NPI:1750367033
Name:WYLIE, BRADFORD BITTNER (MD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:BITTNER
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 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:7093 DEXTER ANN ARBOR RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-8568
Practice Address - Country:US
Practice Address - Phone:734-426-9028
Practice Address - Fax:734-426-9029
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108127972OtherBCBS
MI459558310Medicaid
MI459558310Medicaid
MI1108127972OtherBCBS