MEDICARE: TIMOTHY WILLIAM SOPP D.C.

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	111NI0013X	Independent Medical Examiner Chiropractor	4184	OH
2	111N00000X	Chiropractor	4184	OH

General Provider Information

NPI Number	:	1740576594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY WILLIAM SOPP D.C.

Provider Business Mailing Address
First Line	:	145 RADIO CITY BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-8939
Country	:	US
Telephone Number	:	614-888-7900
Fax Number	:	614-888-7970

Provider Business Practice Location Address
First Line	:	9039 ANTARES AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43240-4067
Country	:	US
Telephone Number	:	614-888-7900
Fax Number	:	614-888-7970

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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