Healthcare Provider Details

I. General information

NPI: 1932165198
Provider Name (Legal Business Name): TIMOTHY C FABIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

877 JEFFERSON AVE ATTN: PROVIDER ENROLLMENT
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-7857
  • Fax: 901-448-7306
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number12911
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number12911
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: