Provider Demographics
NPI:1275558918
Name:TILLEY, ABSALOM H (MD)
Entity Type:Individual
Prefix:
First Name:ABSALOM
Middle Name:H
Last Name:TILLEY
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 1:1003 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4811
Mailing Address - Country:US
Mailing Address - Phone:479-437-3449
Mailing Address - Fax:479-243-0285
Practice Address - Street 1:1003 SCHNEIDER DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4811
Practice Address - Country:US
Practice Address - Phone:501-337-5678
Practice Address - Fax:501-332-6759
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK36912207R00000X
CODR.00655596207R00000X
ARC7758207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117040001Medicaid
AR117040001Medicaid
AR53463Medicare PIN