Provider Demographics
NPI:1023346186
Name:TILLEY, CHARLES PATRICK (NP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PATRICK
Last Name:TILLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 BROADWAY
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3701
Mailing Address - Country:US
Mailing Address - Phone:917-763-8716
Mailing Address - Fax:
Practice Address - Street 1:1250 BROADWAY
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3701
Practice Address - Country:US
Practice Address - Phone:917-763-8716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305286315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03487405Medicaid