Healthcare Provider Details

I. General information

NPI: 1265498273
Provider Name (Legal Business Name): RALEIGH WILLIS ROLLINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CENTRE POINTE BLVD SO EASTERN UROLOGICAL CENTER PA
TALL FL
32308
US

IV. Provider business mailing address

2000 CENTRE POINTE BLVD SO EASTERN UROLOGICAL CENTER PA
TALL FL
32308
US

V. Phone/Fax

Practice location:
  • Phone: 850-309-0400
  • Fax: 850-309-0404
Mailing address:
  • Phone: 850-309-0400
  • Fax: 850-309-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0020010
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: