Provider Demographics
NPI:1275599706
Name:TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.
Entity Type:Organization
Organization Name:TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:TILLGES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:651-772-2665
Mailing Address - Street 1:1570 BEAM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1166
Mailing Address - Country:US
Mailing Address - Phone:651-772-2665
Mailing Address - Fax:651-771-6553
Practice Address - Street 1:563 BIELENBERG DR
Practice Address - Street 2:SUITE 110
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1415
Practice Address - Country:US
Practice Address - Phone:651-735-0818
Practice Address - Fax:651-735-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54075Medicaid
MN21446OtherHEALTH PARTNERS
WI41783200Medicaid
MN102162OtherUCARE
MN2G045TIOtherBLUECROSS/BLUE SHIELD
MN1018417OtherPREFERRED ONE
MN8200377OtherMEDICA
MN0380560002Medicare NSC