=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093058307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TILAK RAJ BABA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2013
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 KIMEL PARK DR STE 200
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-6967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-6211
-----------------------------------------------------
Fax | 336-768-6869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 KIMEL PARK DR STE 200
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-6967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-768-6211
-----------------------------------------------------
Fax | 336-768-6869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | MD044449
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | D0081092
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 202203303
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------