Healthcare Provider Details

I. General information

NPI: 1255537239
Provider Name (Legal Business Name): ETHAN WADE TOLBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE SUITE 1185
ATLANTA GA
30308-2247
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1072
US

V. Phone/Fax

Practice location:
  • Phone: 404-223-0792
  • Fax: 404-223-5815
Mailing address:
  • Phone: 404-223-0792
  • Fax: 404-223-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number46265
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: