Healthcare Provider Details

I. General information

NPI: 1891781225
Provider Name (Legal Business Name): CHARLES H TILLMAN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 MEDICAL PARK DR
MEXICO MO
65265-3726
US

IV. Provider business mailing address

201 E MONROE ST
MEXICO MO
65265-2852
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-3240
  • Fax: 573-581-7493
Mailing address:
  • Phone: 573-581-3240
  • Fax: 573-581-7493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: