Healthcare Provider Details

I. General information

NPI: 1043577315
Provider Name (Legal Business Name): MONICA TILLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONICA KAITZ

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE BLDG 9
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

PO BOX 7464
SAN FRANCISCO CA
94120-7464
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-6581
  • Fax:
Mailing address:
  • Phone: 415-206-6581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA122926
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA122926
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA122926
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: