Basic Information
| Provider Information | |||||||||
| NPI: | 1447260633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN TUYL | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 RIVERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703456600 | ||||||||
| FaxNumber: | 7703456611 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 RIVERSTONE DR | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703456600 | ||||||||
| FaxNumber: | 7703456611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 030684 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207K00000X | 030684 | GA | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207KA0200X | 030684 | GA | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 00509187D | 05 | GA | MEDICAID |