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1912992082

NPI Code Detail

MEDICARE: THADDEUS REX TOLLESON MD

MEDICARE: THADDEUS REX TOLLESON MD

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	207RC0000X	Cardiovascular Disease Physician	J6770	TX
2	207RI0011X	Interventional Cardiology Physician	J6770	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	221985502	OTHER	TX	UNITED HEALTHCARE
2	8G7380	OTHER	TX	BCBS
3	8V5491	OTHER	TX	BCBS TRINITY
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	7773430	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1912992082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THADDEUS REX TOLLESON MD

Provider Business Mailing Address
First Line	:	619 S FLEISHEL AVE
Second Line	:	SUITE 101
City	:	TYLER
State	:	TX
Zip	:	75701-2004
Country	:	US
Telephone Number	:	903-595-5514
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 S FLEISHEL AVE
Second Line	:	SUITE 101
City	:	TYLER
State	:	TX
Zip	:	75701-2004
Country	:	US
Telephone Number	:	903-595-5514
Fax Number	:

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	04/26/2017

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Directions to “ THADDEUS REX TOLLESON MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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