Provider Demographics
NPI:1417988163
Name:TILLISCH, JANET K (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:K
Last Name:TILLISCH
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:1702 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-364-3300
Practice Address - Fax:701-364-8906
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4237208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDND100012OtherLHS #
ND015795300Medicaid
ND28064TIOtherMNBS #
ND91423TIOtherMNBS #
ND1201177OtherMEDICA #
ND1203181OtherMEDICA #
ND142074OtherUCARE #
ND1877OtherNDBS #
ND10168Medicaid
ND1201797OtherMEDICA #
MN6419OtherNDBS #
ND765120OtherAMERICA'S PPO/ARAZ #
ND8253OtherSIOUX VALLEY #
NDDA9011015596OtherPREFERRED ONE #
NDHP19569OtherHEALTHPARTNERS #
ND142074OtherUCARE #
ND10168Medicaid