Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YP0228X | Pediatric Otolaryngology | 25MA06549000 | NJ |
NPI | 1417030792 |
---|---|
Provider Name | Michael Andrew Tavill |
First Address | Tarrytown, NY 10591-5139 |
Second Address | Shrewsbury, NJ 07702 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 01/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G45931 | (02) |