1750332995 NPI number — DR. TIMOTHY G CLOONAN M.D.

Table of content: DR. TIMOTHY G CLOONAN M.D. (NPI 1750332995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750332995 NPI number — DR. TIMOTHY G CLOONAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOONAN
Provider First Name:
TIMOTHY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
1750332995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1390 KELLY JOHNSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80920-3908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-593-1799
Provider Business Mailing Address Fax Number:
719-265-3794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 N CIRCLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80909-1175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-593-1799
Provider Business Practice Location Address Fax Number:
719-265-3794
Provider Enumeration Date:
05/12/2006

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: 2085R0202X , with the licence number:  49946 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200279180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2271518 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11989 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4300613100 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000196823 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 42872286 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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