Provider Demographics
NPI:1184986671
Name:ROLISON, CORTIE J IV (DO)
Entity type:Individual
Prefix:DR
First Name:CORTIE
Middle Name:J
Last Name:ROLISON
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:26 W JACKSON COMMONS DR
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-1897
Practice Address - Country:US
Practice Address - Phone:770-848-9190
Practice Address - Fax:706-658-2462
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL1577207Q00000X
KY03799207QS0010X
GA71278207QS0010X
GA071278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPI #OtherTRICARE
SCNPI #OtherBLUE CHOICE COMMERCIAL
SCNPI #OtherBLUE CROSS NETWORK
SCNPI #OtherBLUE CHOICE MEDICAID
SC015771Medicaid
SC015771Medicaid