Provider Demographics
NPI:1275648099
Name:TILLEY, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:TILLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:TILLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0555
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:1110 BROAD AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8907
Practice Address - Country:US
Practice Address - Phone:228-864-0314
Practice Address - Fax:228-864-0425
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112524Medicaid
MS110105095OtherRAILROAD MEDICARE
MS110105095OtherRAILROAD MEDICARE
MS$$$$$$$$$BOtherBCBS
MS00112524Medicaid
MS512I110231Medicare PIN
MS$$$$$$$$$COtherBCBS
MS302I115952Medicare PIN