Provider Demographics
NPI:1376538801
Name:TYLER CARDIOVASCULAR CONSULTANTS P.A.
Entity Type:Organization
Organization Name:TYLER CARDIOVASCULAR CONSULTANTS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:R
Authorized Official - Last Name:TOLLESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-5514
Mailing Address - Street 1:2608 MCDONALD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5934
Mailing Address - Country:US
Mailing Address - Phone:903-595-5514
Mailing Address - Fax:
Practice Address - Street 1:2608 MCDONALD RD STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5934
Practice Address - Country:US
Practice Address - Phone:903-595-5514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00065KOtherBCBS OF TEXAS
TX079756501Medicaid
TX079756501Medicaid
TXCN7303Medicare PIN