Healthcare Provider Details

I. General information

NPI: 1114970696
Provider Name (Legal Business Name): ADRIENNE G TILBOR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3691 RUTGER ST PROVIDER ENROLLMENT
SAINT LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5600
  • Fax: 314-268-6468
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2005016795
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: