Provider Demographics
NPI:1386738508
Name:TIM THISTLETHWAITE, M.D. PLLC
Entity type:Organization
Organization Name:TIM THISTLETHWAITE, M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:THISTLETHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-205-5207
Mailing Address - Street 1:100 PEYTON WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-8767
Mailing Address - Country:US
Mailing Address - Phone:304-205-5207
Mailing Address - Fax:304-205-5318
Practice Address - Street 1:100 PEYTON WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8767
Practice Address - Country:US
Practice Address - Phone:304-205-5207
Practice Address - Fax:304-205-5318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1225101YP2500X
WV174982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV=========OtherFEDERAL TAX ID