Basic Information
| Provider Information | |||||||||
| NPI: | 1316144033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | TIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 780 | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265070780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042937401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31 TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | HARPERS FERRY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254259519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045356343 | ||||||||
| FaxNumber: | 3045356618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22940 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00623101 | 01 | WV | RAILROAD MEDICARE | OTHER | CA7030 | 01 | WV | RAILROAD MEDICARE GROUP # | OTHER | 3810012381 | 05 | WV | MEDICAID |