1275897225 NPI number — DR. REGAN MICHELE TILLEY D.O.

Table of content: DR. REGAN MICHELE TILLEY D.O. (NPI 1275897225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275897225 NPI number — DR. REGAN MICHELE TILLEY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TILLEY
Provider First Name:
REGAN
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DULIN
Provider Other First Name:
REGAN
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275897225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7840 E US 24 HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-775-1155
Provider Business Mailing Address Fax Number:
785-775-1156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7840 E US 24 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANHATTAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-775-1155
Provider Business Practice Location Address Fax Number:
785-775-1156
Provider Enumeration Date:
06/25/2012

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: 207Q00000X , with the licence number:  2012020612 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 05-38045 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 068002327 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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