Provider Demographics
NPI:1467473801
Name:FITZGIBBON, TIMOTHY A
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:FITZGIBBON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2503
Mailing Address - Country:US
Mailing Address - Phone:843-774-7336
Mailing Address - Fax:843-774-3745
Practice Address - Street 1:603 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2503
Practice Address - Country:US
Practice Address - Phone:843-774-7336
Practice Address - Fax:843-774-3745
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC140118Medicaid
SC140118Medicaid
SC0205300001Medicare NSC