Provider Demographics
NPI:1063510956
Name:TILEY, EDWARD HENRY III (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:HENRY
Last Name:TILEY
Suffix:III
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 1:9 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-925-3115
Mailing Address - Fax:304-925-2088
Practice Address - Street 1:9 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2699
Practice Address - Country:US
Practice Address - Phone:304-925-3115
Practice Address - Fax:304-925-2088
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV127742086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128612000Medicaid
WVA72223Medicare UPIN
WV0128612000Medicaid