Basic Information
| Provider Information | |||||||||
| NPI: | 1477644565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNNE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNNE | ||||||||
| OtherFirstName: | TIMOTHY | ||||||||
| OtherMiddleName: | ANTHONY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 E WATAUGA AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233883643 | ||||||||
| FaxNumber: | 4233883561 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E WATAUGA AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233883643 | ||||||||
| FaxNumber: | 4233883561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2238 | OH | N | Chiropractic Providers | Chiropractor | 111N00000X | 2301007102 | MI | N | Chiropractic Providers | Chiropractor | 111NR0400X | 2552 | TN | Y | Chiropractic Providers | Chiropractor | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 000000316403 | 01 | OH | ANTHEM | OTHER | 950E810930 | 01 | MI | BCBSM | OTHER | 4311318 | 01 | TN | BCBST | OTHER | 2186558 | 05 | OH | MEDICAID |