1962513515 NPI number — CHERYL GATEWOOD TOLLIVER M.D.

Table of content: CHERYL GATEWOOD TOLLIVER M.D. (NPI 1962513515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962513515 NPI number — CHERYL GATEWOOD TOLLIVER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOLLIVER
Provider First Name:
CHERYL
Provider Middle Name:
GATEWOOD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GATEWOOD
Provider Other First Name:
CHERYL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962513515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 E 18TH STREET
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-3422
Provider Business Mailing Address Fax Number:
229-353-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2225 US HIGHWAY 41 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-391-4100
Provider Business Practice Location Address Fax Number:
229-391-4508
Provider Enumeration Date:
08/31/2006

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: 208000000X , with the licence number:  053040 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102002 . This is a "BCBS - EAPC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 752710901A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37BBGMH . This is a "MEDICARE ID PEDIATRICS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52002201 . This is a "BCBS - LMAC" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 7688493 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00051346 . This is a "RR MCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com