Provider Demographics
NPI:1215126206
Name:W. CRAIG TYREE, MD, PLC
Entity type:Organization
Organization Name:W. CRAIG TYREE, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-659-0184
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-0416
Mailing Address - Country:US
Mailing Address - Phone:270-659-0184
Mailing Address - Fax:270-651-9264
Practice Address - Street 1:103 TRISTA LN
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3482
Practice Address - Country:US
Practice Address - Phone:270-659-0184
Practice Address - Fax:270-651-9264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34721174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000364525OtherANTHEM GROUP NUMBER
KY64047186Medicaid
KY9669Medicare PIN