Provider Demographics
NPI:1144393844
Name:TILLY, ELENA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:
Last Name:TILLY
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 1:16800 QUEEN ANNE BRIDGE RD
Mailing Address - Street 2:PHYSICIAN BILLING
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3433
Mailing Address - Country:US
Mailing Address - Phone:301-775-3272
Mailing Address - Fax:
Practice Address - Street 1:300 BYRN ST
Practice Address - Street 2:DORCHESTER GENERAL HOSPITAL
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1908
Practice Address - Country:US
Practice Address - Phone:410-228-5511
Practice Address - Fax:410-221-8783
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044796207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV0583AMedicare PIN
E31798Medicare UPIN