Provider Demographics
NPI:1467532572
Name:TILLMAN, TIMOTHY J (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 SISKIYOU BLVD
Mailing Address - Street 2:PMB 17
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2241
Mailing Address - Country:US
Mailing Address - Phone:541-552-0388
Mailing Address - Fax:866-738-3305
Practice Address - Street 1:185 B ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1910
Practice Address - Country:US
Practice Address - Phone:541-552-0388
Practice Address - Fax:866-738-3305
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275285Medicaid
OR825811000OtherBLUECROSS BLUESHIELD
ORQ00943Medicare UPIN
OR275285Medicaid