MEDICARE: EDWARD HENRY TILEY III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	12774	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063510956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD HENRY TILEY III M.D.

Provider Business Mailing Address
First Line	:	9 COURTNEY DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-2699
Country	:	US
Telephone Number	:	304-925-3115
Fax Number	:	304-925-2088

Provider Business Practice Location Address
First Line	:	9 COURTNEY DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25304-2699
Country	:	US
Telephone Number	:	304-925-3115
Fax Number	:	304-925-2088

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/23/2012

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