1255969960 NPI number — DR. COLLETTE MARIA TILLY MD

Table of content: DR. COLLETTE MARIA TILLY MD (NPI 1255969960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255969960 NPI number — DR. COLLETTE MARIA TILLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLY
Provider First Name:
COLLETTE
Provider Middle Name:
MARIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255969960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
030 MACNIDER HALL CAMPUS BOX 7231
Provider Second Line Business Mailing Address:
333 SOUTH COLUMBIA STREET
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-962-3624
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MANNING DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27599-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-962-3624
Provider Business Practice Location Address Fax Number:
501-364-4082
Provider Enumeration Date:
03/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  E-17847 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: E-17847 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 2025-01613 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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