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General NPI Number Information
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NPI Number | 1003872714
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Entity Type | Individual
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Provider Name | ELBERT STINSON TILLERSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/21/2006
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Last Update Date | 01/15/2013
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Provider Practice Location Address
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Address Line | 1125 MADISON ST.
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City | JEFFERSON CITY
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State | MO
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Zip | 65102-1128
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Country | US
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Telephone | 573-635-7651
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Fax | 573-659-4515
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Provider Business Mailing Address
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Address Line | 1125 MADISON ST.
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City | JEFFERSON CITY
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State | MO
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Zip | 65102-1128
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Country | US
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Telephone | 573-635-7651
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Fax | 573-659-4515
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 2011041481
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 2011041481
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License Number State | MO
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