Provider Demographics
NPI:1841329489
Name:COURTNEY, TYLA
Entity type:Individual
Prefix:DR
First Name:TYLA
Middle Name:
Last Name:COURTNEY
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:PO BOX 2211
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-0211
Mailing Address - Country:US
Mailing Address - Phone:773-484-4425
Mailing Address - Fax:
Practice Address - Street 1:2875 W 19TH ST
Practice Address - Street 2:PHYSICIAN CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3501
Practice Address - Country:US
Practice Address - Phone:773-484-4425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074585Medicaid
0031603374OtherBLUE CROSS BLUE SHIELD
363749530OtherTYCO MEDICAL CLINIC
0031603374OtherBLUE CROSS BLUE SHIELD
ILC44428Medicare UPIN