Healthcare Provider Details

I. General information

NPI: 1588664247
Provider Name (Legal Business Name): TIMOTHY E SOULE-REGINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S MAIN ST STE 1
ATHOL MA
01331-2117
US

IV. Provider business mailing address

201 S MAIN ST STE 1
ATHOL MA
01331-2117
US

V. Phone/Fax

Practice location:
  • Phone: 978-248-3840
  • Fax: 978-249-7227
Mailing address:
  • Phone: 978-248-3840
  • Fax: 978-249-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: