Healthcare Provider Details

I. General information

NPI: 1831108331
Provider Name (Legal Business Name): TILLEY DIAGNOSTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 SCHNEIDER DR
MALVERN AR
72104-4811
US

IV. Provider business mailing address

1003 SCHNEIDER DR
MALVERN AR
72104-4811
US

V. Phone/Fax

Practice location:
  • Phone: 501-337-5678
  • Fax: 501-332-6759
Mailing address:
  • Phone: 501-337-5678
  • Fax: 501-332-6759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC7758
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberE5172
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE5062
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberGL008
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberP01341
License Number StateAR
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01943
License Number StateAR

VIII. Authorized Official

Name: ABSALOM H TILLEY
Title or Position: OWNER
Credential: M.D.
Phone: 501-337-5678