Basic Information
| Provider Information | |||||||||
| NPI: | 1447428362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILFORD | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 ST. ANTOINE UHC 6F | ||||||||
| Address2: | UNIVERSITY PEDIATRICIANS MAILBOX# 226 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139665051 | ||||||||
| FaxNumber: | 3139660665 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN | ||||||||
| Address2: | CHILDREN'S HOSPITAL OF MI | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455629 | ||||||||
| FaxNumber: | 3139660105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 01067045 | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 2080P0203X | 01067045 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200952500 | 05 | IN | MEDICAID |