Provider Demographics
NPI:1891709341
Name:TILLMAN, GAYLE FAITH (MD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:FAITH
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:TURNPIKE STATION
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-0062
Mailing Address - Country:US
Mailing Address - Phone:508-334-8815
Mailing Address - Fax:508-334-5374
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-2062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2301832085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2126354Medicaid
MA2126354Medicaid
I66423Medicare UPIN