Provider Demographics
NPI:1134185341
Name:TIMOTHY TOM MD PA
Entity type:Organization
Organization Name:TIMOTHY TOM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-277-8151
Mailing Address - Street 1:P.O. BOX 504738
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4738
Mailing Address - Country:US
Mailing Address - Phone:888-447-7220
Mailing Address - Fax:336-884-1643
Practice Address - Street 1:1311 GENERAL CAVAZOS BLVD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7129
Practice Address - Country:US
Practice Address - Phone:361-595-9738
Practice Address - Fax:361-595-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0006EAOtherTEXAS BCBS
TX00213UMedicare ID - Type UnspecifiedTEXAS MEDICARE