Healthcare Provider Details

I. General information

NPI: 1144078304
Provider Name (Legal Business Name): SHELBY MAI TILLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

IV. Provider business mailing address

21464 HYDE LN
BEND OR
97701-9569
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-7944
  • Fax:
Mailing address:
  • Phone: 541-408-2270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR80839
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: