Provider Demographics
NPI:1922091214
Name:TILSON, PAUL J (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:TILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:412 NORTHSIDE DR E
Mailing Address - Street 2:#500
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4802
Mailing Address - Country:US
Mailing Address - Phone:912-764-6808
Mailing Address - Fax:912-764-2436
Practice Address - Street 1:412 NORTHSIDE DR E
Practice Address - Street 2:#500
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4802
Practice Address - Country:US
Practice Address - Phone:912-764-6808
Practice Address - Fax:912-764-2436
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020839208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051284OtherBCBS
GA000264382AMedicaid
GA000264382AMedicaid
GA051284OtherBCBS