Basic Information
| Provider Information | |||||||||
| NPI: | 1073830790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | CHIN-YU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 BAPTIST DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391102009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016052383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22583 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22583 | 01 | MS | LICENSE NUMBER | OTHER | FC3881136 | 01 | MS | DEA NUMBER | OTHER | 164441 | 01 | NC | RESIDENT TRAINING LICENSE | OTHER |