MEDICARE: DR MARY TILAK P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RB0002X	Obesity Medicine (Internal Medicine) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000541656	OTHER	IN	ANTHEM
2	90001352	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1003096900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MARY TILAK P C

Provider Business Mailing Address
First Line	:	2241 45TH ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-2601
Country	:	US
Telephone Number	:	219-922-8051
Fax Number	:	219-922-8608

Provider Business Practice Location Address
First Line	:	2241 45TH ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-2601
Country	:	US
Telephone Number	:	219-922-8051
Fax Number	:	219-922-8608

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARY N. TILAK
Credential	:	M.D.
Telephone Number	:	219-922-8051

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	04/14/2011

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