Healthcare Provider Details

I. General information

NPI: 1952322893
Provider Name (Legal Business Name): MEXICO CARDIOVASCULAR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 MEDICAL PARK DR
MEXICO MO
65265-3726
US

IV. Provider business mailing address

720 MEDICAL PARK DR
MEXICO MO
65265-3726
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: DR. CHARLES HERBERT TILLMAN JR.
Title or Position: OWNER/PARTNER
Credential: M.D.
Phone: 573-581-3240