Provider Demographics
NPI:1346273901
Name:TILLMAN EYECARE EAST P.C.
Entity Type:Organization
Organization Name:TILLMAN EYECARE EAST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANDIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-476-4936
Mailing Address - Street 1:1700 S GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-5744
Mailing Address - Country:US
Mailing Address - Phone:812-476-4936
Mailing Address - Fax:812-962-4300
Practice Address - Street 1:1700 S GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-5744
Practice Address - Country:US
Practice Address - Phone:812-476-4936
Practice Address - Fax:812-962-4300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002713B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000356037OtherANTHEM
INP00229910Medicare ID - Type UnspecifiedRAILROAD
IN220700AMedicare ID - Type Unspecified
IN000000356037OtherANTHEM