Basic Information
| Provider Information | |||||||||
| NPI: | 1346286465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLIVER | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100A DRAKE'S LANDING ROAD | ||||||||
| Address2: | STE 225 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159241214 | ||||||||
| FaxNumber: | 4159241375 | ||||||||
| Practice Location | |||||||||
| Address1: | 100A DRAKE'S LANDING ROAD | ||||||||
| Address2: | STE 225 | ||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159241214 | ||||||||
| FaxNumber: | 4159241375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 08/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | A88295 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A882950 | 05 | CA | MEDICAID | 1346286465 | 01 | CA | TYPE 1 NPI | OTHER |