MEDICARE: DR. STEPHEN B TILLEY 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	207Q00000X	Family Medicine Physician	C4672	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11217000000	OTHER	AR	QUALCHOICE
2	01-20334	OTHER	AR	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1205833738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN B TILLEY MD

Provider Business Mailing Address
First Line	:	701 N UNIVERSITY
Second Line	:	SUITE 201
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205
Country	:	US
Telephone Number	:	501-224-1690
Fax Number	:	501-224-1927

Provider Business Practice Location Address
First Line	:	5905 R ST
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72207
Country	:	US
Telephone Number	:	501-663-9415
Fax Number	:	501-663-1874

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	04/17/2008

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