Basic Information
| Provider Information | |||||||||
| NPI: | 1588651020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENDERGRASS | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 TUSKEGEE BLVD | ||||||||
| Address2: | 436 MDG CC STE 1B22 | ||||||||
| City: | DOVER AFB | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199025300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026772525 | ||||||||
| FaxNumber: | 3026772526 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 TUSKEGEE BLVD | ||||||||
| Address2: | 436 MDG CC STE 1B22 | ||||||||
| City: | DOVER AFB | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199025300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026772525 | ||||||||
| FaxNumber: | 3026772526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5757 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.