Basic Information
| Provider Information | |||||||||
| NPI: | 1831360965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TILLOU | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265924 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ENGLISH CREEK AVE. | ||||||||
| Address2: | BLDG 800 | ||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094072332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 247883 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 25MA10853800 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02976612 | 05 | NY | MEDICAID | 000417727001 | 01 | NY | BLUE SHIELD NENY | OTHER | 110135661 | 01 | CDPHP | OTHER | 3024552 | 01 | MVP | OTHER |