Healthcare Provider Details

I. General information

NPI: 1669476586
Provider Name (Legal Business Name): TIMOTHY RICHARD KINSEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY STE 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2191
  • Fax: 706-721-4920
Mailing address:
  • Phone: 706-828-8402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101235162
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: