Provider Demographics
NPI:1154311306
Name:TILLER, THOMAS L JR (M D)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:TILLER
Suffix:JR
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CREEKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4800
Mailing Address - Country:US
Mailing Address - Phone:864-458-7431
Mailing Address - Fax:864-458-7463
Practice Address - Street 1:48 CREEKVIEW CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-458-7431
Practice Address - Fax:864-458-7463
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4841207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC048415Medicaid
SC048415Medicaid
D17825Medicare UPIN