Provider Demographics
NPI:1982665121
Name:TOLLISON, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:TOLLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3300
Mailing Address - Country:US
Mailing Address - Phone:864-234-5800
Mailing Address - Fax:864-284-0844
Practice Address - Street 1:319 S BUNCOMBE RD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1207
Practice Address - Country:US
Practice Address - Phone:864-877-9883
Practice Address - Fax:864-284-0844
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC102962Medicaid
B91948Medicare UPIN
SC102962Medicaid