Basic Information
| Provider Information | |||||||||
| NPI: | 1801885298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BICKNELL | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 PORTER DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057538527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023888808 | ||||||||
| FaxNumber: | 8023888322 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | VERGENNES | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054911107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028773466 | ||||||||
| FaxNumber: | 8028771188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 042 0009191 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | OVN1240 | 05 | VT | MEDICAID |