Basic Information
Provider Information | |||||||||
NPI: | 1417988163 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TILLISCH | ||||||||
FirstName: | JANET | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6001 | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581086001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013643300 | ||||||||
FaxNumber: | 7013648906 | ||||||||
Practice Location | |||||||||
Address1: | 1702 UNIVERSITY DR S | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581034940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013643300 | ||||||||
FaxNumber: | 7013648906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 11/03/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4237 | ND | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | ND100012 | 01 | ND | LHS # | OTHER | 015795300 | 05 | ND |   | MEDICAID | 28064TI | 01 | ND | MNBS # | OTHER | 91423TI | 01 | ND | MNBS # | OTHER | 1201177 | 01 | ND | MEDICA # | OTHER | 1203181 | 01 | ND | MEDICA # | OTHER | 142074 | 01 | ND | UCARE # | OTHER | 1877 | 01 | ND | NDBS # | OTHER | 10168 | 05 | ND |   | MEDICAID | 1201797 | 01 | ND | MEDICA # | OTHER | 6419 | 01 | MN | NDBS # | OTHER | 765120 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | 8253 | 01 | ND | SIOUX VALLEY # | OTHER | DA9011015596 | 01 | ND | PREFERRED ONE # | OTHER | HP19569 | 01 | ND | HEALTHPARTNERS # | OTHER |