Basic Information
| Provider Information | |||||||||
| NPI: | 1417945932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488989060 | ||||||||
| FaxNumber: | 2485510557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 4301507714 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | G7971 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZC0500X | 25714 | MS | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 129406807 | 05 | TX | MEDICAID |