Basic Information
| Provider Information | |||||||||
| NPI: | 1942313515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TILLMAN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13385 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852673385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 W THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 18859 | AZ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 287591 | 05 | AZ | MEDICAID |