Healthcare Provider Details

I. General information

NPI: 1245471069
Provider Name (Legal Business Name): GILMAN R TYLER MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 S AUDUBON AVE STE A
TAMPA FL
33609-4217
US

IV. Provider business mailing address

602 S AUDUBON AVE STE A
TAMPA FL
33609-4217
US

V. Phone/Fax

Practice location:
  • Phone: 813-877-1415
  • Fax:
Mailing address:
  • Phone: 813-877-1415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME48678
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME48678
License Number StateFL

VIII. Authorized Official

Name: JENNIFER MARTINEZ
Title or Position: BILLING
Credential:
Phone: 813-496-1075