Basic Information
Provider Information | |||||||||
NPI: | 1659453520 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGLOTHLIN | ||||||||
FirstName: | WYLIE | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 652 | ||||||||
Address2: | SUITE 310 | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473620652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655993400 | ||||||||
FaxNumber: | 7655993500 | ||||||||
Practice Location | |||||||||
Address1: | 2200 FOREST RIDGE PKWY | ||||||||
Address2: | SUITE 310 | ||||||||
City: | NEW CASTLE | ||||||||
State: | IN | ||||||||
PostalCode: | 473622943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655993400 | ||||||||
FaxNumber: | 7655993500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 05/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01026722 | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QG0300X | 01026722 | IN | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 2000563106 | 05 | IN |   | MEDICAID | 200056310 | 05 | IN |   | MEDICAID |