Provider Demographics
NPI:1265498273
Name:ROLLINS, RALEIGH WILLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RALEIGH
Middle Name:WILLIS
Last Name:ROLLINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CENTRE POINTE BLVD
Mailing Address - Street 2:SO EASTERN UROLOGICAL CENTER PA
Mailing Address - City:TALL
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-309-0400
Mailing Address - Fax:850-309-0404
Practice Address - Street 1:2000 CENTRE POINTE BLVD
Practice Address - Street 2:SO EASTERN UROLOGICAL CENTER PA
Practice Address - City:TALL
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-309-0400
Practice Address - Fax:850-309-0404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0020010208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00166779AMedicaid
FL37213OtherBCBS
D54578Medicare UPIN
FL37213ZMedicare ID - Type Unspecified