Provider Demographics
NPI:1073566014
Name:TILT, ELIZABETH ELLEN (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:TILT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 LISA CAROL DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-7903
Mailing Address - Country:US
Mailing Address - Phone:704-651-3907
Mailing Address - Fax:704-799-1627
Practice Address - Street 1:511 LISA CAROL DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-7903
Practice Address - Country:US
Practice Address - Phone:704-651-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-00744208000000X, 2080A0000X
NC9500744208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8983534Medicaid