Basic Information
Provider Information | |||||||||
NPI: | 1518072156 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOVOSEL | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936857 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 311936857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106629300 | ||||||||
FaxNumber: | 9106622401 | ||||||||
Practice Location | |||||||||
Address1: | 1725 NEW HANOVER MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284035345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106629300 | ||||||||
FaxNumber: | 9106622401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 05/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101232753 | VA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 2018-01072 | NC | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | 0101232753 | VA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 2018-01072 | NC | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
ID | Type | State | Issuer | Description | -019 | 01 | VA | TRICARE/CHAMPUS | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 10012521 | 01 | VA | SENTARA OPTIMA | OTHER | 2018-01072 | 01 | NC | MEDICAL LICENSE | OTHER | 221095 | 01 | VA | ANTHEM | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER |