1548403231 NPI number — TIMOTHY P VANDERBILT M.D.

Table of content: TIMOTHY P VANDERBILT M.D. (NPI 1548403231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548403231 NPI number — TIMOTHY P VANDERBILT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERBILT
Provider First Name:
TIMOTHY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548403231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 FISH HATCHERY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53715-1909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-252-8000
Provider Business Mailing Address Fax Number:
608-288-6495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 FISH HATCHERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53715-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-252-8000
Provider Business Practice Location Address Fax Number:
608-288-6495
Provider Enumeration Date:
04/11/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  55868-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 17227 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 102696 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1548403231 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".