Provider Demographics
NPI:1700889540
Name:ROLLE, GARRISON A (MD)
Entity Type:Individual
Prefix:
First Name:GARRISON
Middle Name:A
Last Name:ROLLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8405
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:850-877-5636
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:STE 400
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8405
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:850-877-5636
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68918207XX0005X, 207X00000X
GA047143207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000815372AMedicaid
GA000815372CMedicaid
FL252503800Medicaid
FL252503800Medicaid
GA20BBFFBMedicare ID - Type Unspecified
FLG29274Medicare UPIN
FL42496Medicare ID - Type UnspecifiedTALLAHASSEE