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General NPI Number Information
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NPI Number | 1386738508
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Entity Type | Organization
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Legal Business Name | TIM THISTLETHWAITE, M.D. PLLC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 10/04/2013
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Provider Practice Location Address
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Address Line | 100 PEYTON WAY SUITE 100
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City | CHARLESTON
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State | WV
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Zip | 25309-8767
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Country | US
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Telephone | 304-205-5207
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Fax | 304-205-5318
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Provider Business Mailing Address
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Address Line | 100 PEYTON WAY SUITE 100
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City | CHARLESTON
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State | WV
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Zip | 25309-8767
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Country | US
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Telephone | 304-205-5207
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Fax | 304-205-5318
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIM L THISTLETHWAITE
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Credential | M.D.
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Telephone | 304-205-5207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1225
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 17498
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License Number State | WV
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