Healthcare Provider Details

I. General information

NPI: 1043260615
Provider Name (Legal Business Name): TILLMAN MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT ST
VIDALIA LA
71373-2836
US

IV. Provider business mailing address

107 FRONT ST
VIDALIA LA
71373-2836
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2216
  • Fax:
Mailing address:
  • Phone: 318-336-2216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5D595
License Number StateLA

VIII. Authorized Official

Name: TANA L ARCHER
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 318-336-2216