Provider Demographics
NPI:1700859485
Name:CLOSE, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:CLOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1247
Mailing Address - Country:US
Mailing Address - Phone:803-462-3770
Mailing Address - Fax:803-462-3771
Practice Address - Street 1:2000 PARK ST
Practice Address - Street 2:STE 202
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2011
Practice Address - Country:US
Practice Address - Phone:803-462-3770
Practice Address - Fax:803-462-3771
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC145742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE17853Medicare UPIN
SCE178534823Medicare ID - Type Unspecified