Provider Demographics
NPI:1629022967
Name:TISCH, IRA S (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:S
Last Name:TISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:IRA
Other - Middle Name:
Other - Last Name:TISCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:555 FRENCH RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1044
Mailing Address - Country:US
Mailing Address - Phone:315-735-3541
Mailing Address - Fax:315-724-3255
Practice Address - Street 1:555 FRENCH RD
Practice Address - Street 2:SUITE 103
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1044
Practice Address - Country:US
Practice Address - Phone:315-735-3541
Practice Address - Fax:315-724-3255
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1576065207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01748907Medicaid
NYF20723Medicare UPIN
NYP00174251Medicare PIN
NYRA3054Medicare PIN