Provider Demographics
NPI:1740596907
Name:THOM L TYLER, MD, PA
Entity Type:Organization
Organization Name:THOM L TYLER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:352-333-5000
Mailing Address - Street 1:6440 W NEWBERRY RD STE 408
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4370
Mailing Address - Country:US
Mailing Address - Phone:352-333-5000
Mailing Address - Fax:352-333-5006
Practice Address - Street 1:6440 W NEWBERRY RD STE 408
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4370
Practice Address - Country:US
Practice Address - Phone:352-333-5000
Practice Address - Fax:352-333-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36132173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066787100Medicaid
FLD50080Medicare UPIN