=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831360965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY J. TILLOU M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2008
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 ENGLISH CREEK AVE. BLDG 800
-----------------------------------------------------
City | EGG HARBOR TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-407-2332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 PARK ST
-----------------------------------------------------
City | GLENS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12801-4413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-926-5924
-----------------------------------------------------
Fax | 518-926-6983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 247883
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 25MA10853800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------