1831108331 NPI number — TILLEY DIAGNOSTIC CLINIC

Table of content: (NPI 1831108331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831108331 NPI number — TILLEY DIAGNOSTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TILLEY DIAGNOSTIC CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PINNACLE PHYSICIANS GROUP
Provider Other Organization Name Type Code:
3
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:
1831108331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1003 SCHNEIDER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALVERN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72104-4811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-337-5678
Provider Business Mailing Address Fax Number:
501-332-6759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 SCHNEIDER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALVERN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72104-4811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-337-5678
Provider Business Practice Location Address Fax Number:
501-332-6759
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TILLEY
Authorized Official First Name:
ABSALOM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
501-337-5678

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  C7758 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RR0500X , with the licence number: E5172 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: E5062 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: GL008 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: P01341 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: A01943 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 149122002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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