Healthcare Provider Details

I. General information

NPI: 1821016502
Provider Name (Legal Business Name): ANITA M. TILLMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE SUITE 2500
NORMAL IL
61761-3551
US

IV. Provider business mailing address

701 LEE ST SUITE 300
DES PLAINES IL
60016-4539
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2770
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036084299
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036084299
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 2
Identifier5723019
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: