Provider Demographics
NPI:1720007248
Name:TILTON, JAMES RANDOLPH JR (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RANDOLPH
Last Name:TILTON
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 DILTS RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-9475
Mailing Address - Country:US
Mailing Address - Phone:989-875-2266
Mailing Address - Fax:989-875-2225
Practice Address - Street 1:203 DILTS RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-9475
Practice Address - Country:US
Practice Address - Phone:989-875-2266
Practice Address - Fax:989-875-2225
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA2741KD1Medicaid
200770947OtherTAX ID
MI650B910270OtherBCBSM AND BCN
MI607648000OtherOFFICE OF WORKERS COMP.
MI64-70128OtherPHP
MI7594704OtherAETNA
MI7594704OtherAETNA