Basic Information
| Provider Information | |||||||||
| NPI: | 1538159751 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT L WYENANDT JR,MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2156 CHAMBER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2156 CHAMBER CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | WYENANDT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8593416255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.