Provider Demographics
NPI:1801866835
Name:SHORT, TIMOTHY B (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:B
Last Name:SHORT
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LEE ST FL 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-243-6361
Practice Address - Fax:434-243-6280
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040226207Q00000X, 207QH0002X, 207RH0002X
IL036-126666207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080141641OtherMEDICARE PIN
VA234064OtherANTHEM SVC/HEALTHKEEPERS
VA267138OtherMAMSI
VA700010935OtherCIGNA
VA45187Medicaid
VA142901OtherSOUTHERN HEALTH
VAP00212563OtherMEDICARE PIN
VA005638623Medicaid
VA45187OtherCOMMUNITY HEALTH
IL450690009Medicare PIN
VA700010935OtherCIGNA
B60235Medicare UPIN
VAP00212563OtherMEDICARE PIN
VA142901OtherSOUTHERN HEALTH