Provider Demographics
NPI:1891781225
Name:TILLMAN, CHARLES H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:TILLMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:201 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2852
Mailing Address - Country:US
Mailing Address - Phone:573-581-3240
Mailing Address - Fax:573-581-7493
Practice Address - Street 1:720 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3726
Practice Address - Country:US
Practice Address - Phone:573-581-3240
Practice Address - Fax:573-581-7493
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO36412207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202409801Medicaid