1295714954 NPI number — CHRISTOPHER LEEDS TILLOTSON MD

Table of content: SHAKIMA MILLS (NPI 1912870007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295714954 NPI number — CHRISTOPHER LEEDS TILLOTSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLOTSON
Provider First Name:
CHRISTOPHER
Provider Middle Name:
LEEDS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1295714954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7130 KENMARE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55438-2834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7595 ANAGRAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-7399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-573-2200
Provider Business Practice Location Address Fax Number:
612-573-2274
Provider Enumeration Date:
01/11/2006

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: 2085R0202X , with the licence number:  32771 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32368200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 48603TI . This is a "BLUE CROSS BLUE SHIELD OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 100718 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1604147 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7562520 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23018 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9246569 . This is a "DAKOTA CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1021804 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 99112160 . This is a "WI HEALTH INSURANCE RISK SHARING PLAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: P00437108 . This is a "RAILROAD MEDICARE WI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 300085357 . This is a "RAILROAD MEDICARE MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 674795700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP14559 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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