MEDICARE: ELBERT STINSON TILLERSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	2011041481	MO
2	208M00000X	Hospitalist Physician	2011041481	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	054133	OTHER	GA	LICENSE
2	23919	OTHER	SC	1
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003872714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELBERT STINSON TILLERSON MD

Provider Business Mailing Address
First Line	:	1125 MADISON ST.
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-1128
Country	:	US
Telephone Number	:	573-635-7651
Fax Number	:	573-659-4515

Provider Business Practice Location Address
First Line	:	1125 MADISON ST.
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-1128
Country	:	US
Telephone Number	:	573-635-7651
Fax Number	:	573-659-4515

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	01/15/2013

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