Basic Information
Provider Information | |||||||||
NPI: | 1447212014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLLI | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 37TH ST N | ||||||||
Address2: | SUITE C | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337136010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273281001 | ||||||||
FaxNumber: | 7273270413 | ||||||||
Practice Location | |||||||||
Address1: | 1001 37TH ST N | ||||||||
Address2: | SUITE C | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337136010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273281001 | ||||||||
FaxNumber: | 7273270413 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2006 | ||||||||
LastUpdateDate: | 12/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0069472 | FL | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 252227600 | 05 | FL |   | MEDICAID |