Basic Information
| Provider Information | |||||||||
| NPI: | 1255537239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLBERT | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042230792 | ||||||||
| FaxNumber: | 4042235815 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | SUITE 1185 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042230792 | ||||||||
| FaxNumber: | 4042235815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 46265 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 463493784D | 05 | GA | MEDICAID |