MEDICARE: TIM DOUGLASS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle	RP410135	OH

General Provider Information

NPI Number	:	1679960124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIM DOUGLASS

Provider Business Mailing Address
First Line	:	14060 VINCENT RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-8283
Country	:	US
Telephone Number	:	740-485-8529
Fax Number	:

Provider Business Practice Location Address
First Line	:	14060 VINCENT RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-8283
Country	:	US
Telephone Number	:	740-485-8529
Fax Number	:

Authorized Official
Title or Position	:	DRIVER
Name	:	TIM D DOUGLASS
Credential	:
Telephone Number	:	740-485-8529

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/22/2015

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