Provider Demographics
NPI:1639253636
Name:TILLY, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TILLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12261 W 159TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-7847
Mailing Address - Country:US
Mailing Address - Phone:708-301-2255
Mailing Address - Fax:708-301-2631
Practice Address - Street 1:12261 W 159TH ST
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-7847
Practice Address - Country:US
Practice Address - Phone:708-301-2255
Practice Address - Fax:708-301-2631
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-124552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623066OtherBCBS PROVIDER #
IL367885100OtherU.S. DEPT. OF LABOR PROV
ILCJ4383OtherR.R. MEDICARE GROUP #
ILK04123Medicare PIN
IL1623066OtherBCBS PROVIDER #
IL567770Medicare ID - Type UnspecifiedMEDICARE GROUP #