Provider Demographics
NPI:1003872714
Name:TILLERSON, ELBERT STINSON (MD)
Entity Type:Individual
Prefix:
First Name:ELBERT
Middle Name:STINSON
Last Name:TILLERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MADISON ST.
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1128
Mailing Address - Country:US
Mailing Address - Phone:573-635-7651
Mailing Address - Fax:573-659-4515
Practice Address - Street 1:1125 MADISON ST.
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65102-1128
Practice Address - Country:US
Practice Address - Phone:573-635-7651
Practice Address - Fax:573-659-4515
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110414812084P0800X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054133OtherLICENSE
SC23919Other1
MO1003872714Medicaid
SC23919Other1