Provider Demographics
NPI:1417030792
Name:TAVILL, MICHAEL ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:TAVILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 WHITE PLAINS RD FL 4
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5139
Mailing Address - Country:US
Mailing Address - Phone:914-984-2546
Mailing Address - Fax:
Practice Address - Street 1:1131 BROAD STREET
Practice Address - Street 2:STE 103
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-389-3388
Practice Address - Fax:732-389-3389
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06549000207YS0012X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G45931Medicare UPIN
NJ897868MDFMedicare ID - Type Unspecified