Provider Demographics
NPI:1235119090
Name:TILLEM, STEVEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:M
Last Name:TILLEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3119 NEWTOWN AVE
Mailing Address - Street 2:SUITE 801
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-1350
Mailing Address - Country:US
Mailing Address - Phone:718-777-2111
Mailing Address - Fax:718-732-2191
Practice Address - Street 1:3119 NEWTOWN AVE
Practice Address - Street 2:SUITE 801
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1350
Practice Address - Country:US
Practice Address - Phone:718-777-2111
Practice Address - Fax:718-732-2191
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1982311208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02057289Medicaid
NY02057289Medicaid
NYG82453Medicare UPIN
NY08199JMedicare PIN