Provider Demographics
NPI:1942633250
Name:TYLISZ, PAULA D
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:D
Last Name:TYLISZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 W 275 N
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9306
Mailing Address - Country:US
Mailing Address - Phone:219-308-0859
Mailing Address - Fax:800-894-6690
Practice Address - Street 1:7625 W 275 N
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9306
Practice Address - Country:US
Practice Address - Phone:219-308-0859
Practice Address - Fax:800-894-6690
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8945249139343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201168400 AMedicaid