Provider Demographics
NPI:1134109465
Name:TILLETT, ROBERT SIDNEY JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SIDNEY
Last Name:TILLETT
Suffix:JR
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3991 DUTCHMANS LN STE 310
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4716
Practice Address - Country:US
Practice Address - Phone:502-899-6782
Practice Address - Fax:502-899-6783
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY202662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50030136OtherPASSPORT/PASSPORT ADVANTAGE - NNS
KY000000693343OtherANTHEM - NNS
KY118916OtherSIHO - NNS
KY000057043WOtherHUMANA - NNS
IN100388800Medicaid
KY2542960OtherCIGNA - NNS
KY64202666Medicaid
KY50030136OtherPASSPORT/PASSPORT ADVANTAGE - NNS
IN100388800Medicaid
KYC70939Medicare UPIN
KYP400024417Medicare PIN
KY00546102Medicare PIN