Provider Demographics
NPI:1073566014
Name:TILT, ELIZABETH ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:TILT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 GATEWAY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5608
Mailing Address - Country:US
Mailing Address - Phone:704-799-2878
Mailing Address - Fax:704-799-1627
Practice Address - Street 1:136 GATEWAY BLVD STE A
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5608
Practice Address - Country:US
Practice Address - Phone:704-799-2878
Practice Address - Fax:704-799-1627
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-007442080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8983534Medicaid