Provider Demographics
NPI:1093860504
Name:TILLEM, ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:TILLEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE
Mailing Address - City:BRONX
Mailing Address - State:NJ
Mailing Address - Zip Code:10456
Mailing Address - Country:US
Mailing Address - Phone:718-518-5046
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:BRONX
Practice Address - State:NJ
Practice Address - Zip Code:10456
Practice Address - Country:US
Practice Address - Phone:718-518-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225727207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine