Basic Information
| Provider Information | |||||||||
| NPI: | 1962513515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLIVER | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | GATEWOOD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GATEWOOD | ||||||||
| OtherFirstName: | CHERYL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 907 E 18TH STREET | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
| FaxNumber: | 2293536060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 US HIGHWAY 41 N | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317942749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293914100 | ||||||||
| FaxNumber: | 2293914508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 053040 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 102002 | 01 | GA | BCBS - EAPC | OTHER | 752710901A | 05 | GA | MEDICAID | 37BBGMH | 01 | GA | MEDICARE ID PEDIATRICS | OTHER | 52002201 | 01 | GA | BCBS - LMAC | OTHER | 7688493 | 01 | GA | AETNA | OTHER | P00051346 | 01 | GA | RR MCARE | OTHER |