Provider Demographics
NPI:1578507984
Name:TILLMAN, RONALD CLYDE (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:CLYDE
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 N BELLS ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-1767
Mailing Address - Country:US
Mailing Address - Phone:731-696-5551
Mailing Address - Fax:731-696-2802
Practice Address - Street 1:157 N BELLS ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001-1767
Practice Address - Country:US
Practice Address - Phone:731-696-5551
Practice Address - Fax:731-696-2802
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3728156Medicaid
TNB59490Medicare UPIN
TN3728156Medicaid