Healthcare Provider Details

I. General information

NPI: 1477880664
Provider Name (Legal Business Name): MARC O TILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MAPLE AVE
WARWICK NY
10990-1028
US

IV. Provider business mailing address

PO BOX 875
WARWICK NY
10990-0875
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-2006
  • Fax: 845-615-1590
Mailing address:
  • Phone: 845-294-2006
  • Fax: 845-615-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2050577-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: