MEDICARE: DR. RONALD MARK TILSEN 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	207R00000X	Internal Medicine Physician	G34508	CA

General Provider Information

NPI Number	:	1801852280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD MARK TILSEN M.D.

Provider Business Mailing Address
First Line	:	400 NEWPORT CENTER DR
Second Line	:	SUITE 608
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7601
Country	:	US
Telephone Number	:	949-644-3559
Fax Number	:	949-718-6729

Provider Business Practice Location Address
First Line	:	400 NEWPORT CENTER DR
Second Line	:	SUITE 608
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7601
Country	:	US
Telephone Number	:	949-644-3559
Fax Number	:	949-718-6729

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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