Provider Demographics
NPI:1831108331
Name:TILLEY DIAGNOSTIC CLINIC
Entity Type:Organization
Organization Name:TILLEY DIAGNOSTIC CLINIC
Other - Org Name:PINNACLE PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABSALOM
Authorized Official - Middle Name:H
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-337-5678
Mailing Address - Street 1:1003 SCHNEIDER DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4811
Mailing Address - Country:US
Mailing Address - Phone:501-337-5678
Mailing Address - Fax:501-332-6759
Practice Address - Street 1:1003 SCHNEIDER DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4811
Practice Address - Country:US
Practice Address - Phone:501-337-5678
Practice Address - Fax:501-332-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7758207R00000X, 207R00000X
ARE5172207RR0500X
ARE5062208000000X
ARGL008363A00000X
ARP01341363L00000X
ARA01943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149122002Medicaid
AR149122002Medicaid