Healthcare Provider Details

I. General information

NPI: 1518240092
Provider Name (Legal Business Name): MR. MATTHEW W TILL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E PAULDING RD
FORT WAYNE IN
46816-1223
US

IV. Provider business mailing address

1701 E PAULDING RD
FORT WAYNE IN
46816-1223
US

V. Phone/Fax

Practice location:
  • Phone: 260-456-3429
  • Fax:
Mailing address:
  • Phone: 260-456-3429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number26091940A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: