=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669783221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JAMES HENSHAW M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 06/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6335 CORNTASSEL LN
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-5625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-776-1553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6335 CORNTASSEL LN
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-5625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-798-9965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 0101056544
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------