Provider Demographics
NPI:1932178332
Name:TILLEY, JAMES BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRADLEY
Last Name:TILLEY
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 1:495 HOGAN RD, STE 1
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-327-1150
Mailing Address - Fax:501-327-3427
Practice Address - Street 1:495 HOGAN RD, STE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-327-1150
Practice Address - Fax:501-327-3427
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2822208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146509001Medicaid
ARH60908Medicare UPIN