Provider Demographics
NPI:1689602211
Name:TILLERY, JEFFRY MARK (MD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:MARK
Last Name:TILLERY
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 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8500
Mailing Address - Fax:815-639-8501
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8500
Practice Address - Fax:815-639-8501
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078730Medicaid
IL553180OtherMEDICARE GROUP #
IL553180006Medicare PIN
IL080051087Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL834340Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILL52862Medicare ID - Type Unspecified
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
IL036078730Medicaid
IL553180OtherMEDICARE GROUP #
ILE64513Medicare UPIN