Provider Demographics
NPI:1548366354
Name:TILLEY, ROGER L (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:TILLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 ALCOA
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3404
Mailing Address - Country:US
Mailing Address - Phone:501-315-4512
Mailing Address - Fax:501-315-0917
Practice Address - Street 1:624 ALCOA
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3404
Practice Address - Country:US
Practice Address - Phone:501-315-4512
Practice Address - Fax:501-315-0917
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5458207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105495001Medicaid
D04958Medicare UPIN
AR105495001Medicaid