Healthcare Provider Details

I. General information

NPI: 1356674394
Provider Name (Legal Business Name): TILLIAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SE COURT AVE
PENDLETON OR
97801-3217
US

IV. Provider business mailing address

PO BOX 1893
CORVALLIS OR
97339-1893
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-3228
  • Fax: 541-278-3219
Mailing address:
  • Phone: 541-758-5047
  • Fax: 541-758-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD29432
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARK OWEN MCVEE
Title or Position: PRESIDENT
Credential: MD
Phone: 541-758-5047