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General NPI Number Information
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NPI Number | 1891781225
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Entity Type | Individual
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Provider Name | CHARLES H TILLMAN JR. MD
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Gender | Male
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Dates
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Enumeration Date | 09/21/2005
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Last Update Date | 07/28/2023
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Provider Practice Location Address
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Address Line | 720 MEDICAL PARK DR
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City | MEXICO
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State | MO
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Zip | 65265-3726
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Country | US
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Telephone | 573-581-3240
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Fax | 573-581-7493
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Provider Business Mailing Address
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Address Line | 201 E MONROE ST
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City | MEXICO
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State | MO
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Zip | 65265-2852
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Country | US
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Telephone | 573-581-3240
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Fax | 573-581-7493
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 36412
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License Number State | MO
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