1275648099 NPI number — DR. RICHARD TILLEY M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275648099 NPI number — DR. RICHARD TILLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLEY
Provider First Name:
RICHARD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TILLEY
Provider Other First Name:
RICHARD
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1275648099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 555
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39533-0555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-864-8454
Provider Business Mailing Address Fax Number:
228-865-1457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 BROAD AVE
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-8907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-864-0314
Provider Business Practice Location Address Fax Number:
228-864-0425
Provider Enumeration Date:
08/20/2006

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:  07061 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00112524 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110105095 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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