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NPI Code Detail

MEDICARE: DR. SHANNON L TILLY MD

MEDICARE: DR. SHANNON L TILLY MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207V00000XObstetrics & Gynecology Physician54125001205UT

General Provider Information

NPI Number : 1093767196
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHANNON L TILLY MD
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1525 W 2100 S
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84119-1401
Country : US
Telephone Number : 801-213-9900
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2006
Last Update Date : 08/10/2021

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Directions to “ DR. SHANNON L TILLY MD” Practice Location

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