Provider Demographics
NPI:1437704079
Name:OTYLIA PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:OTYLIA PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRZYSZTOF
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-878-3366
Mailing Address - Street 1:4913 RALEIGH COMMON DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-2485
Mailing Address - Country:US
Mailing Address - Phone:901-878-3366
Mailing Address - Fax:901-492-4941
Practice Address - Street 1:4913 RALEIGH COMMON DR STE 201
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2485
Practice Address - Country:US
Practice Address - Phone:901-878-3366
Practice Address - Fax:901-492-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty