1578556981 NPI number — TIMOTHY WARD TOURVILLE MED, ATC, CSCS

Table of content: TIMOTHY WARD TOURVILLE MED, ATC, CSCS (NPI 1578556981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578556981 NPI number — TIMOTHY WARD TOURVILLE MED, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOURVILLE
Provider First Name:
TIMOTHY
Provider Middle Name:
WARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED, ATC, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578556981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 JUNIPER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-5793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-656-3239
Provider Business Mailing Address Fax Number:
802-656-4247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 CARRIGAN DR
Provider Second Line Business Practice Location Address:
STAFFORD HALL 4 MCCLURE MUSCULOSKELETAL RESEARCH CENTER
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05405-1746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-656-3239
Provider Business Practice Location Address Fax Number:
802-656-4247
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  104-0000032 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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