Basic Information
| Provider Information | |||||||||
| NPI: | 1538119953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIRITILLI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 ESKENAZI AVE | ||||||||
| Address2: | FIFTH THIRD BANK BLDG, 5TH FL | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462024166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178804121 | ||||||||
| FaxNumber: | 3178800343 | ||||||||
| Practice Location | |||||||||
| Address1: | 9443 E 38TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462352132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178902100 | ||||||||
| FaxNumber: | 3178902171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01043935A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100200080 | 05 | IN | MEDICAID |