Healthcare Provider Details

I. General information

NPI: 1447831623
Provider Name (Legal Business Name): ILANA TIDUS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N PERRY ST
PONTIAC MI
48342-2217
US

IV. Provider business mailing address

50 N PERRY ST
PONTIAC MI
48342-2217
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-5392
  • Fax: 248-338-5567
Mailing address:
  • Phone: 248-338-5392
  • Fax: 248-338-5567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number011226
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: