Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XP3100X | Pediatric Orthopaedic Surgeon | 25MA02117500 | NJ |
NPI | 1750593356 |
---|---|
Provider Name | Dr. Alan C. Tillis |
First Address | Livingston, NJ 07039-8236 |
Second Address | Livingston, NJ 07039-8236 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C58365 | (02) | NJ |