Basic Information
| Provider Information | |||||||||
| NPI: | 1962404996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMMONS | ||||||||
| FirstName: | BENSON | ||||||||
| MiddleName: | ELLISON LANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1072 X RAY DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046711094 | ||||||||
| FaxNumber: | 7046711095 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 N NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048664005 | ||||||||
| FaxNumber: | 7048660450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 39341 | NC | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0122X | 39341 | NC | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8354X | 01 | BCBS | OTHER | 2165882F | 01 | MEDICARE | OTHER | 898354X | 05 | NC | MEDICAID | 2165882G | 01 | MEDICARE | OTHER |