Provider Demographics
NPI:1013555671
Name:TOLAN, MERRITT MCCOY
Entity Type:Individual
Prefix:
First Name:MERRITT
Middle Name:MCCOY
Last Name:TOLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1362
Practice Address - Street 1:600 E PALMETTO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2851
Practice Address - Country:US
Practice Address - Phone:843-667-9414
Practice Address - Fax:843-667-1362
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16788207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC167884Medicaid