Basic Information
Provider Information | |||||||||
NPI: | 1093710261 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TILBEN | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | ELAINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 21300 N JOHN WAYNE PKWY STE 115 | ||||||||
Address2: |   | ||||||||
City: | MARICOPA | ||||||||
State: | AZ | ||||||||
PostalCode: | 851398978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204263424 | ||||||||
FaxNumber: | 5205689560 | ||||||||
Practice Location | |||||||||
Address1: | 21300 N JOHN WAYNE PKWY STE 115 | ||||||||
Address2: |   | ||||||||
City: | MARICOPA | ||||||||
State: | AZ | ||||||||
PostalCode: | 851398978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204263424 | ||||||||
FaxNumber: | 5205689560 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2005 | ||||||||
LastUpdateDate: | 02/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3992 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0410400 | 01 | AZ | CIGNA | OTHER | 5955103 | 01 | AZ | AETNA | OTHER | 921347 | 05 | AZ |   | MEDICAID | 41956 | 01 | AZ | UNIVERSAL HEALTHCARE | OTHER | P01230458 | 01 | AZ | RAILROAD MCR | OTHER |