Basic Information
| Provider Information | |||||||||
| NPI: | 1124095310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAW | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DEEMER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 PARKS HALL | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405932516 | ||||||||
| FaxNumber: | 7405932905 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 PARKS HALL | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405932516 | ||||||||
| FaxNumber: | 7405932905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 12/19/2012 | ||||||||
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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 | 207Q00000X | 02493 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34006410 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5044438 | 01 | KY | AETNA | OTHER | 64024938 | 05 | KY | MEDICAID | 000000191820 | 01 | KY | ANTHEM BC BS | OTHER |