Provider Demographics
NPI:1578752796
Name:ROLAND A. TOLLIVER
Entity Type:Organization
Organization Name:ROLAND A. TOLLIVER
Other - Org Name:FREEPORT PODIATRY SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOLLIVER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-232-8015
Mailing Address - Street 1:1201 W EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6106
Mailing Address - Country:US
Mailing Address - Phone:815-232-8015
Mailing Address - Fax:815-235-1376
Practice Address - Street 1:1201 W EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6106
Practice Address - Country:US
Practice Address - Phone:815-232-8015
Practice Address - Fax:815-235-1376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003850213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003850Medicaid
IL0060201289OtherBLUE CROSS BLUE SHIELD
ILT38801Medicare UPIN
IL4456080001Medicare NSC
IL016003850Medicaid