Provider Demographics
NPI:1922124312
Name:TILLMAN MEDICAL GROUP PA
Entity Type:Organization
Organization Name:TILLMAN MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:318-339-4112
Mailing Address - Street 1:800 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71343
Mailing Address - Country:US
Mailing Address - Phone:318-339-4112
Mailing Address - Fax:318-339-6388
Practice Address - Street 1:800 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71343
Practice Address - Country:US
Practice Address - Phone:318-339-4112
Practice Address - Fax:318-339-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07480R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447498Medicaid
LA193858Medicare Oscar/Certification