Healthcare Provider Details

I. General information

NPI: 1609802511
Provider Name (Legal Business Name): TOMISLAV M. JELIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVENUE SE PATHOLOGY DEPARTMENT
CHARLESTON WV
25304
US

IV. Provider business mailing address

415 MORRIS STREET SUITE 304
CHARLESTON WV
25301
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5550
  • Fax: 304-388-4352
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number17984
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: