Provider Demographics
NPI:1952322893
Name:MEXICO CARDIOVASCULAR ASSOCIATES LLC
Entity Type:Organization
Organization Name:MEXICO CARDIOVASCULAR ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:573-581-3240
Mailing Address - Street 1:720 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3726
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36412207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA13078Medicare UPIN
MOC51976Medicare UPIN