Provider Demographics
NPI:1083691141
Name:TILL, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:TILL
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 1:74 FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465-2081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3191
Practice Address - Country:US
Practice Address - Phone:802-879-1802
Practice Address - Fax:802-878-6131
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT7744207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009288Medicaid
VT5218501OtherVERMONT MANAGED CARE
VT16V016OtherMVP
VT00004552OtherBCBS
VT0009288Medicaid
VT5218501OtherVERMONT MANAGED CARE