Provider Demographics
NPI:1104059955
Name:WILEY ROOSTH MD & ASSOCIATES
Entity type:Organization
Organization Name:WILEY ROOSTH MD & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOSTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-592-8181
Mailing Address - Street 1:1025 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2023
Mailing Address - Country:US
Mailing Address - Phone:903-592-8181
Mailing Address - Fax:903-592-8113
Practice Address - Street 1:1025 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2023
Practice Address - Country:US
Practice Address - Phone:903-592-8181
Practice Address - Fax:903-592-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB9174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030768801Medicaid
B26009Medicare UPIN
TX030768801Medicaid