Healthcare Provider Details

I. General information

NPI: 1497076053
Provider Name (Legal Business Name): TIMOTHY MICHAEL FOELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL DR NE
BOLIVIA NC
28422-8346
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-721-2070
  • Fax: 910-721-2074
Mailing address:
  • Phone: 910-721-2070
  • Fax: 910-721-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA141573
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125-058488
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019013057
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDR.0071799
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2023-01534
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: