Healthcare Provider Details

I. General information

NPI: 1366419137
Provider Name (Legal Business Name): BRYCE R TILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 UNIVERSITY BLVD S
JACKSONVILLE FL
32216-4207
US

IV. Provider business mailing address

PO BOX 860554
ORLANDO FL
32886-0554
US

V. Phone/Fax

Practice location:
  • Phone: 904-399-6811
  • Fax: 904-346-0113
Mailing address:
  • Phone: 904-346-3606
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number049114
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME0082274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: