=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477880664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC O TILLER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 11/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 MAPLE AVE
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10990-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-294-2006
-----------------------------------------------------
Fax | 845-615-1590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 875
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10990-0875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-294-2006
-----------------------------------------------------
Fax | 845-615-1590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2050577-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------