Basic Information
| Provider Information | |||||||||
| NPI: | 1831467935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TILI MEDICAL OFFICE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5830 MAIN ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188862820 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5830 MAIN ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188862820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | LIANG | ||||||||
| AuthorizedOfficialFirstName: | WEINING | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7188862820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170100000X | 203586 | NY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Medical Genetics, Ph.D. Medical Genetics |
ID Information
| ID | Type | State | Issuer | Description | 203586 | 01 | NY | LICENSE | OTHER |