Provider Demographics
NPI:1609044197
Name:LAWRENCE E TILLEY, MDPA
Entity Type:Organization
Organization Name:LAWRENCE E TILLEY, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-475-8599
Mailing Address - Street 1:23000 MOAKLEY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-8599
Mailing Address - Fax:
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-8599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD28647207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D76602Medicare UPIN