Basic Information
Provider Information | |||||||||
NPI: | 1033108071 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLEMING | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 449 MOUNTAIN VIEW ST | ||||||||
Address2: |   | ||||||||
City: | POWELL | ||||||||
State: | WY | ||||||||
PostalCode: | 824352232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077544559 | ||||||||
FaxNumber: | 3077547733 | ||||||||
Practice Location | |||||||||
Address1: | 1511 CHARLES AVE | ||||||||
Address2: |   | ||||||||
City: | WORLAND | ||||||||
State: | WY | ||||||||
PostalCode: | 824014122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073472405 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2005 | ||||||||
LastUpdateDate: | 02/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 2071A | WY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 06006340 | 01 | WY | RAILROAD MEDICARE | OTHER | 115857100 | 05 | WY |   | MEDICAID | 308637 | 01 | WY | BLUE CROSS BLUE SHEILD | OTHER | 0032810 | 05 | MT |   | MEDICAID |