Provider Demographics
NPI:1962586974
Name:WYTHE GASTROENTERLOGY
Entity type:Organization
Organization Name:WYTHE GASTROENTERLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-228-2383
Mailing Address - Street 1:590 W RIDGE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1094
Mailing Address - Country:US
Mailing Address - Phone:276-228-2383
Mailing Address - Fax:276-228-5829
Practice Address - Street 1:590 W RIDGE RD
Practice Address - Street 2:SUITE E
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1094
Practice Address - Country:US
Practice Address - Phone:276-228-2383
Practice Address - Fax:276-228-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA248472OtherBCBS OF VA
VADF4627OtherRAILROAD MEDICARE GROUP
VAC09998OtherMEDICARE GROUP #
VAC09998OtherMEDICARE GROUP #
VADF4627OtherRAILROAD MEDICARE GROUP