Basic Information
| Provider Information | |||||||||
| NPI: | 1124344502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DHMC DEPARTMENT OF PEDIATRICS | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036539663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DHMC DEPARTMENT OF PEDIATRICS | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036539850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2010 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 16197 | NH | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080N0001X | 16197 | NH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1021949 | 05 | VT | MEDICAID | 3086958 | 05 | NH | MEDICAID |