Provider Demographics
NPI:1144475864
Name:TIM MCNICOLL MD INC
Entity type:Organization
Organization Name:TIM MCNICOLL MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCNICOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-527-6424
Mailing Address - Street 1:2876 SYCAMORE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1530
Mailing Address - Country:US
Mailing Address - Phone:805-527-6424
Mailing Address - Fax:805-522-0115
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1530
Practice Address - Country:US
Practice Address - Phone:805-527-6424
Practice Address - Fax:805-522-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G481000Medicaid
CAE89826Medicare UPIN
CAG48100Medicare PIN