Provider Demographics
NPI:1306935317
Name:TILLEMANS, KIM (DO)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:TILLEMANS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-302-8275
Mailing Address - Fax:
Practice Address - Street 1:1020 WEST BROADWAY
Practice Address - Street 2:UMP BROADWAY FAMILY MEDICINE URGENT CARE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411
Practice Address - Country:US
Practice Address - Phone:612-302-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47806207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0596106Medicaid
WI43523000Medicaid
MNHP54459OtherHEALTHPARTNERS
MN66-08643OtherMEDICA
I35027Medicare UPIN
080014291Medicare ID - Type Unspecified