Provider Demographics
NPI:1700208337
Name:TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.
Entity Type:Organization
Organization Name:TILLGES CERTIFIED ORTHOTIC PROSTHETIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:TILLGES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, FAAOP
Authorized Official - Phone:651-772-2665
Mailing Address - Street 1:1570 BEAM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1166
Mailing Address - Country:US
Mailing Address - Phone:651-772-2665
Mailing Address - Fax:651-771-6553
Practice Address - Street 1:817 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1145
Practice Address - Country:US
Practice Address - Phone:612-341-3660
Practice Address - Fax:612-341-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1018417OtherPREFERRED ONE
102162OtherUCARE
2G045TIOtherBLUE CROSS BLUE SHIELD
MN78026500Medicaid
21446OtherHEALTHPARTNERS
WI41783200Medicaid
8200377OtherMEDICA