Provider Demographics
NPI:1609802511
Name:JELIC, TOMISLAV M (MD)
Entity Type:Individual
Prefix:
First Name:TOMISLAV
Middle Name:M
Last Name:JELIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:415 MORRIS STREET
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:3200 MACCORKLE AVENUE SE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5550
Practice Address - Fax:304-388-4352
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV17984207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G62212Medicare UPIN
P00827312Medicare PIN
JE4279231Medicare PIN
JE7253641Medicare PIN
WV2E7253641Medicare ID - Type Unspecified