Healthcare Provider Details

I. General information

NPI: 1518077403
Provider Name (Legal Business Name): ANDREA P TISH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 HIGHLAND AVE ER
SALEM MA
01970
US

IV. Provider business mailing address

57 HIGHLAND AVE NORTH SHORE HEALTH SYSTEMS
SALEM MA
01970-2141
US

V. Phone/Fax

Practice location:
  • Phone: 978-354-2815
  • Fax: 978-744-9247
Mailing address:
  • Phone: 978-354-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46187
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: