Healthcare Provider Details

I. General information

NPI: 1790771574
Provider Name (Legal Business Name): JEFFREY R THILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 HIGHWAY 466
LADY LAKE FL
32159-3918
US

IV. Provider business mailing address

2020 SE 17TH ST
OCALA FL
34471-4118
US

V. Phone/Fax

Practice location:
  • Phone: 352-751-0040
  • Fax: 352-751-2825
Mailing address:
  • Phone: 352-732-0277
  • Fax: 352-732-6574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME55997
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: