1033652581 NPI number — JERELYN H TILLER NP

Table of content: JERELYN H TILLER NP (NPI 1033652581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033652581 NPI number — JERELYN H TILLER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLER
Provider First Name:
JERELYN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1033652581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 22ND ST S
Provider Second Line Business Mailing Address:
RIDGE PARK PLACE, SUITE 1000
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35205-2870
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:
2800 ALLISON BONNETT MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUEYTOWN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35023-1845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-744-4410
Provider Business Practice Location Address Fax Number:
205-744-6150
Provider Enumeration Date:
11/30/2016

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: 363LA2200X , with the licence number:  1139395 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LW0102X , with the licence number: 1139395 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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