Provider Demographics
NPI:1306005202
Name:ELLISON, TAMBREA TOYLETT (MD)
Entity type:Individual
Prefix:
First Name:TAMBREA
Middle Name:TOYLETT
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 COLLIER RD NW
Mailing Address - Street 2:APT 1329
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-8232
Mailing Address - Country:US
Mailing Address - Phone:706-210-8027
Mailing Address - Fax:
Practice Address - Street 1:900 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:770-997-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL30874207R00000X
GA69187208VP0014X, 208VP0000X, 208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137503BMedicaid
GA003137503FMedicaid
GA003137503DMedicaid
GA003137503AMedicaid
GA003137503CMedicaid
GA003137503EMedicaid
GA003137503AMedicaid