Provider Demographics
NPI:1396107405
Name:TILLIS, BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:TILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9555 76TH ST # 4105
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1984
Mailing Address - Country:US
Mailing Address - Phone:262-577-8080
Mailing Address - Fax:262-577-8081
Practice Address - Street 1:9555 76TH ST STE 4105
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-577-8080
Practice Address - Fax:262-577-8081
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69543-20207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI69543-20OtherWI LICENSE