Provider Demographics
NPI:1962628743
Name:EDWARD H. TILEY, III, M.D, INC.
Entity Type:Organization
Organization Name:EDWARD H. TILEY, III, M.D, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:TILEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:304-925-3115
Mailing Address - Street 1:9 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-925-3115
Mailing Address - Fax:304-925-2088
Practice Address - Street 1:9 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2699
Practice Address - Country:US
Practice Address - Phone:304-925-3115
Practice Address - Fax:304-925-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12774174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128612000Medicaid
WV9302041Medicare PIN
WV0128612000Medicaid