1245202399 NPI number — MICHAEL R TIMM PAC

Table of content: MICHAEL R TIMM PAC (NPI 1245202399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245202399 NPI number — MICHAEL R TIMM PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIMM
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1245202399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8100 34TH AVE S
Provider Second Line Business Mailing Address:
MAIL STOP 21110Q
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-5463
Provider Business Mailing Address Fax Number:
952-883-5395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 JACKSON ST
Provider Second Line Business Practice Location Address:
MC 11503J
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-254-5701
Provider Business Practice Location Address Fax Number:
651-254-1519
Provider Enumeration Date:
02/03/2006

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: 363A00000X , with the licence number:  9878 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 660159600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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