Healthcare Provider Details

I. General information

NPI: 1144295130
Provider Name (Legal Business Name): TIMOTHY KEITH BULLOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 MONTCLAIR RD SUITE 758
BIRMINGHAM AL
35213-1923
US

IV. Provider business mailing address

513 BROOKWOOD BLVD SUITE 501
BIRMINGHAM AL
35209-6862
US

V. Phone/Fax

Practice location:
  • Phone: 205-930-8020
  • Fax: 205-930-8024
Mailing address:
  • Phone: 205-930-8010
  • Fax: 205-930-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code193400000X
TaxonomySingle Specialty Group
License Number24255
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24255
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: