Provider Demographics
NPI:1174698138
Name:TILLMAN, WAYNE A (DPM)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:A
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 S. 104TH AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1512
Mailing Address - Country:US
Mailing Address - Phone:708-923-0400
Mailing Address - Fax:708-923-0600
Practice Address - Street 1:13011 S. 104TH AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1512
Practice Address - Country:US
Practice Address - Phone:708-923-0400
Practice Address - Fax:708-923-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004926213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2700614OtherUHC
IL1626136OtherBCBS
IL4861340001OtherDMGRC
IL480034104OtherRAILROAD MC
IL2700614OtherUHC
574830Medicare ID - Type Unspecified