Provider Demographics
NPI:1508839390
Name:TILLESON, SCOTT J (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:TILLESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:N17 W24100 RIVERWOOD DRIVE SUITE 250
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:13900 W NATIONAL AVE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-9515
Practice Address - Country:US
Practice Address - Phone:262-928-4500
Practice Address - Fax:262-928-4550
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI19446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30040300Medicaid
WI30040300Medicaid
WI683750666Medicare PIN