Provider Demographics
NPI:1083826093
Name:WYLIE, LINDSAY A (MD)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:A
Last Name:WYLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:ANNE
Other - Last Name:WYLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4885 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 2-10
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1952
Mailing Address - Country:US
Mailing Address - Phone:614-267-7878
Mailing Address - Fax:614-267-7077
Practice Address - Street 1:4885 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 2-10
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1952
Practice Address - Country:US
Practice Address - Phone:614-267-7878
Practice Address - Fax:614-267-7077
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907703Medicaid
SCQ0062KMedicaid
OH0101104Medicaid
OH0101104Medicaid