Basic Information
Provider Information
NPI: 1003298316
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILEBSKI
FirstName: KYLE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
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Mailing Information
Address1: 2813 HAYWARD AVE APT D
Address2:  
City: BROWNSBURG
State: IN
PostalCode: 461120169
CountryCode: US
TelephoneNumber: 7015208049
FaxNumber:  
Practice Location
Address1: 1130 W MICHIGAN ST # FH204
Address2:  
City: INDIANAPOLIS
State: IN
PostalCode: 462025209
CountryCode: US
TelephoneNumber: 3172740076
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/23/2015
LastUpdateDate: 06/10/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208D00000XRL 13722NDN Allopathic & Osteopathic PhysiciansGeneral Practice 
390200000X11018737AINY Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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