Provider Demographics
NPI:1912964321
Name:TILLES, DAN S (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:S
Last Name:TILLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:86 BAKER AVE EXTENSION
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2125
Practice Address - Country:US
Practice Address - Phone:978-287-9300
Practice Address - Fax:978-287-9357
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-05-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA45946207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0172723Medicaid
MAJ07305OtherBLUE CROSS
MA65067OtherHARVARD PILGRIM
MA006170OtherNEIGHBORHOOD HEALTH
MA4109369OtherAETNA
MA715989OtherTUFTS
MAB10208102OtherCIGNA
MAA59310Medicare UPIN
MA4109369OtherAETNA