Healthcare Provider Details

I. General information

NPI: 1356525133
Provider Name (Legal Business Name): DR. MARY TILAK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 EAST 86TH AVENUE
MERRILLVILLE IN
46322-2601
US

IV. Provider business mailing address

209 EAST 86TH AVENUE
MERRILLVILLE IN
46322-2601
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-8051
  • Fax: 219-922-8608
Mailing address:
  • Phone: 219-922-8051
  • Fax: 219-922-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number01054662A
License Number StateIN

VIII. Authorized Official

Name: MARY N. TILAK
Title or Position: PRESIDENT
Credential: MD
Phone: 219-922-8051