Healthcare Provider Details

I. General information

NPI: 1497583850
Provider Name (Legal Business Name): DERRICK NEIL TOLLIVER MEDICAL TRANSPORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 WATERSIDE DR
HAMPTON VA
23666-4216
US

IV. Provider business mailing address

407 WATERSIDE DR
HAMPTON VA
23666-4216
US

V. Phone/Fax

Practice location:
  • Phone: 404-434-7279
  • Fax:
Mailing address:
  • Phone: 404-434-7279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberUCB1780
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: