Provider Demographics
NPI:1134295389
Name:TILLEY, MARTIN GEORGE (MD, DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:GEORGE
Last Name:TILLEY
Suffix:
Gender:M
Credentials:MD, DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 W 39TH ST
Mailing Address - Street 2:SUITE D TOWER PLAZA
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2881
Mailing Address - Country:US
Mailing Address - Phone:308-865-2577
Mailing Address - Fax:308-234-9526
Practice Address - Street 1:516 W 39TH ST
Practice Address - Street 2:SUITE D TOWER PLAZA
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2881
Practice Address - Country:US
Practice Address - Phone:308-865-2577
Practice Address - Fax:308-234-9526
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16420208600000X
NE45601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE3663OtherBLUE CROSS BLUE SHIELD
NE47067456101Medicaid
NE5400OtherBLUE CROSS BLUE SHIELD
NE5400OtherBLUE CROSS BLUE SHIELD
NE095606Medicare ID - Type Unspecified