1508072869 NPI number — MR. DOUGLAS ROGER TILLMAN MS ED, PLMHP

Table of content: MR. DOUGLAS ROGER TILLMAN MS ED, PLMHP (NPI 1508072869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508072869 NPI number — MR. DOUGLAS ROGER TILLMAN MS ED, PLMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLMAN
Provider First Name:
DOUGLAS
Provider Middle Name:
ROGER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS ED, PLMHP
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:
1508072869
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 W 39TH ST APT F8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNEY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68845-2778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-352-8568
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 N ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68801-4254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-395-1025
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2007

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: 101Y00000X , with the licence number:  8297 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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