Provider Demographics
NPI:1326488347
Name:TILLMAN, ABIGAIL (MD)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:TILLMAN
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 1:301 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:315-744-1478
Mailing Address - Fax:315-744-1218
Practice Address - Street 1:4000 MEDICAL CENTER DR SUITE 101DE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-637-7878
Practice Address - Fax:315-637-7870
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312752207Q00000X
CT56540207Q00000X
NY305958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1326488347Medicaid