Provider Demographics
NPI:1831360965
Name:TILLOU, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:TILLOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:2500 ENGLISH CREEK AVE.
Practice Address - Street 2:BLDG 800
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234
Practice Address - Country:US
Practice Address - Phone:609-407-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247883208600000X
NJ25MA10853800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02976612Medicaid
NY000417727001OtherBLUE SHIELD NENY
110135661OtherCDPHP
3024552OtherMVP
3024552OtherMVP