Individual
DR. BRIAN J TOLLEFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 984-5571
(601) 984-5583
Mailing address
504 CLINTON CENTER DRIVE, CBO SUITE 4300, CLINTON, MS 39056-4500
(601) 815-2005
(601) 984-5583
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
18987
MS
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
18987
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
178297
—
AL
05
—
1796778
—
MS
01
—
512I930490
MEDICARE PTAN EFFECTIVE 7/17/09
MS
01
—
P00772006
RAILROAD NUMBER
MS
Enumeration date
07/06/2006
Last updated
03/24/2023
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