Provider Demographics
NPI:1093747776
Name:TOLLEFSON, BRIAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:TOLLEFSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:504 CLINTON CENTER DRIVE
Mailing Address - Street 2:CBO SUITE 4300
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-2005
Mailing Address - Fax:601-984-5583
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5571
Practice Address - Fax:601-984-5583
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18987207P00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00772006OtherRAILROAD NUMBER
AL178297Medicaid
MS512I930490OtherMEDICARE PTAN EFFECTIVE 7/17/09
MS1796778Medicaid
MSP00772006OtherRAILROAD NUMBER