Provider Demographics
NPI:1013952142
Name:TILLER, TRACY (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2701
Mailing Address - Country:US
Mailing Address - Phone:513-221-4949
Mailing Address - Fax:513-221-4954
Practice Address - Street 1:10400 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-1657
Practice Address - Country:US
Practice Address - Phone:513-367-5888
Practice Address - Fax:513-367-1015
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052697T208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0597911Medicaid