Provider Demographics
NPI:1134190614
Name:TILLER, RICK WILLIAM (DPM)
Entity type:Individual
Prefix:DR
First Name:RICK
Middle Name:WILLIAM
Last Name:TILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-5600
Mailing Address - Country:US
Mailing Address - Phone:269-344-0874
Mailing Address - Fax:269-344-7256
Practice Address - Street 1:1212 S PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-5600
Practice Address - Country:US
Practice Address - Phone:269-344-0874
Practice Address - Fax:269-344-7256
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001551213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2756308Medicaid
MI480C97640OtherBLUE CROSS BLUE SHIELD
MIN79480001OtherRAILROAD MEDICARE
MI5395009OtherBLUE CROSS BLUE SHIELD MI
MI0432570002OtherDME
MI480C97640OtherBLUE CARE NETWORK
MI0432570002OtherDME
MI480C97640OtherBLUE CARE NETWORK
MI5824480001Medicare NSC