Basic Information
Provider Information | |||||||||
NPI: | 1699879924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POWELL | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751069 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 517 MOYE BLVD | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278342849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527440766 | ||||||||
FaxNumber: | 2527440392 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2006 | ||||||||
LastUpdateDate: | 12/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2017-00518 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 0101049447 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | 2017-00518 | NC | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 461276 | 01 | VA | ANTHEM | OTHER | 1699879924 | 05 | NC |   | MEDICAID | 010254558 | 05 | VA |   | MEDICAID | 19RGP | 01 | NC | BCBS OF NC | OTHER | NCX793022 | 01 | NC | MEDICARE | OTHER |