Provider Demographics
NPI:1134448814
Name:TILLIS, CEA CHENEA (MD)
Entity type:Individual
Prefix:
First Name:CEA
Middle Name:CHENEA
Last Name:TILLIS
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 1:263 METAIRIE HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-3036
Mailing Address - Country:US
Mailing Address - Phone:504-264-7911
Mailing Address - Fax:
Practice Address - Street 1:263 METAIRIE HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-3036
Practice Address - Country:US
Practice Address - Phone:504-264-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2037342080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09185577Medicaid
LA2120051Medicaid
LA4P2867061Medicare PIN