Healthcare Provider Details

I. General information

NPI: 1376538801
Provider Name (Legal Business Name): TYLER CARDIOVASCULAR CONSULTANTS P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 MCDONALD RD STE 100
TYLER TX
75701-5934
US

IV. Provider business mailing address

2608 MCDONALD RD STE 100
TYLER TX
75701-5934
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-5514
  • Fax:
Mailing address:
  • Phone: 903-595-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: THADDEUS R TOLLESON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 903-595-5514