Healthcare Provider Details

I. General information

NPI: 1336881986
Provider Name (Legal Business Name): TYLER TOLLESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

1600 MEDICAL CENTER DR
HUNTINGTON WV
25701-3656
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5987
  • Fax:
Mailing address:
  • Phone: 304-691-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number47954
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: