Provider Demographics
NPI:1285947911
Name:TILLACK, LINDSEY ANN (MD)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:ANN
Last Name:TILLACK
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 1:518 ALEXANDER WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-2504
Mailing Address - Country:US
Mailing Address - Phone:617-721-7392
Mailing Address - Fax:
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09672400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine