Provider Demographics
NPI:1700838703
Name:TILLETT, EDWARD DAIL (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:DAIL
Last Name:TILLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:STE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-587-7222
Mailing Address - Fax:502-587-0860
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-587-8222
Practice Address - Fax:502-587-0860
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22228207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0773853OtherMEDICARE-UNSPECIFIED
KY64222284Medicaid
KY000000049351OtherANTHEM/UNIV ORTHO ASSOC
KY100374040Medicaid
KY1049630OtherPASSPORT/UNIV ORTHO ASSOC
KY1071560OtherPASSPORT / R G SHEA
KY4043364OtherAETNA / R G SHEA
KY200013351OtherRAILROAD MEDICARE / R G SHEA
KY2434923000OtherPASSPORT ADVANTAGE / R G SHEA
KY000000048044OtherANTHEM / R G SHEA
KY2432607000OtherPASSPORT ADV/UNIV ORTHO A
KYP00693363Medicare PIN
KY4043364OtherAETNA / R G SHEA
KY2434923000OtherPASSPORT ADVANTAGE / R G SHEA
KY0773853OtherMEDICARE-UNSPECIFIED
KY0766146Medicare ID - Type Unspecified
KY0605902Medicare PIN