1295753622 NPI number — ARDRA R DAVIS-TOLBERT MD

Table of content: ARDRA R DAVIS-TOLBERT MD (NPI 1295753622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295753622 NPI number — ARDRA R DAVIS-TOLBERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS-TOLBERT
Provider First Name:
ARDRA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295753622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1264 RIBAUT ROAD
Provider Second Line Business Mailing Address:
BUILDING 200
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-524-5455
Provider Business Mailing Address Fax Number:
843-524-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 BAYLOR DR
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-8965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-540-5857
Provider Business Practice Location Address Fax Number:
843-524-5655
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  225851 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 225851 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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