Healthcare Provider Details

I. General information

NPI: 1255969960
Provider Name (Legal Business Name): COLLETTE MARIA TILLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DRIVE
CHAPEL HILL NC
27599-3500
US

IV. Provider business mailing address

030 MACNIDER HALL CAMPUS BOX 7231 333 SOUTH COLUMBIA STREET
CHAPEL HILL NC
27599
US

V. Phone/Fax

Practice location:
  • Phone: 919-962-3624
  • Fax: 501-364-4082
Mailing address:
  • Phone: 919-962-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-17847
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-17847
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2025-01613
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: