Healthcare Provider Details

I. General information

NPI: 1023837911
Provider Name (Legal Business Name): TIMOTHY MALCOLM MEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 11/04/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 ANDERSON ST
BRISTOL TN
37620-1916
US

IV. Provider business mailing address

908 CHADWICK DR APT 6
KINGSPORT TN
37660-5661
US

V. Phone/Fax

Practice location:
  • Phone: 276-285-8906
  • Fax:
Mailing address:
  • Phone: 276-285-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12052009162300420
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: