Provider Demographics
NPI:1952326753
Name:JAMES RANDOLPH TILTON
Entity Type:Organization
Organization Name:JAMES RANDOLPH TILTON
Other - Org Name:ITHACA PHYSICAL THERAPY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:TILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:989-875-2266
Mailing Address - Street 1:875 E HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-9343
Mailing Address - Country:US
Mailing Address - Phone:989-463-1590
Mailing Address - Fax:989-875-2266
Practice Address - Street 1:203 DILTS RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-9475
Practice Address - Country:US
Practice Address - Phone:989-875-2266
Practice Address - Fax:989-875-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI607647900OtherOFFICE OF WORKER'S COMP.
MI0P20500Medicare ID - Type Unspecified