Basic Information
Provider Information | |||||||||
NPI: | 1679917702 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLEMING | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: | BARRETT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60447 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282600447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367188383 | ||||||||
FaxNumber: | 3367189622 | ||||||||
Practice Location | |||||||||
Address1: | 3333 SILAS CREEK PKWY | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 27103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367188383 | ||||||||
FaxNumber: | 3367189622 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2013 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2019-01420 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | MD177089 | OR | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 2019-01420 | NC | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | R3198 | KY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 500707709 | 05 | OR |   | MEDICAID |