MEDICARE: MEYLON TILLMAN CLARK

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1437862547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEYLON TILLMAN CLARK

Provider Business Mailing Address
First Line	:	6902 MARINA COVE CT
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-2282
Country	:	US
Telephone Number	:	707-332-0351
Fax Number	:

Provider Business Practice Location Address
First Line	:	6902 MARINA COVE CT
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-2282
Country	:	US
Telephone Number	:	707-332-0351
Fax Number	:

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

Provider Enumeration Date	:	01/04/2023
Last Update Date	:	01/04/2023

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Directions to “ MEYLON TILLMAN CLARK ” Practice Location

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