MEDICARE: TAMBREA TOYLETT ELLISON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	LL30874	SC
2	208VP0014X	Interventional Pain Medicine Physician	69187	GA
3	208VP0000X	Pain Medicine Physician	69187	GA
4	208100000X	Physical Medicine & Rehabilitation Physician	69187	GA
5	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	69187	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306005202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMBREA TOYLETT ELLISON M.D.

Provider Business Mailing Address
First Line	:	1185 COLLIER RD NW
Second Line	:	APT 1329
City	:	ATLANTA
State	:	GA
Zip	:	30318-8232
Country	:	US
Telephone Number	:	706-210-8027
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 EAGLES LANDING PKWY
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7343
Country	:	US
Telephone Number	:	770-997-0600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	12/07/2016

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