MEDICARE: AZA TILIS S.ED (MA ED.)

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	174400000X	Specialist	900B	NY

General Provider Information

NPI Number	:	1245592302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZA TILIS S.ED (MA ED.)

Provider Business Mailing Address
First Line	:	2522 AVENUE Y
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2423
Country	:	US
Telephone Number	:	718-332-8842
Fax Number	:	718-332-8842

Provider Business Practice Location Address
First Line	:	2522 AVENUE Y
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2423
Country	:	US
Telephone Number	:	718-332-8842
Fax Number	:	718-332-8842

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/20/2012

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