Provider Demographics
NPI:1497752588
Name:TILTON, THERESA MAE (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAE
Last Name:TILTON
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 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:216-255-5727
Mailing Address - Fax:866-458-9875
Practice Address - Street 1:3021 WINDERMERE ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2950
Practice Address - Country:US
Practice Address - Phone:859-278-5270
Practice Address - Fax:229-928-3492
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME742672085R0202X
KY341032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300138462OtherRR
AZ488628Medicaid
ID808323500Medicaid
KYP00922044OtherRXR MEDICARE
42591OtherBCBS
NY03083272Medicaid
MD221123800Medicaid
KY64927270Medicaid
FL263513500Medicaid
ID808323500Medicaid
FL42591YMedicare PIN
300138462OtherRR
NY03083272Medicaid