Basic Information
| Provider Information | |||||||||
| NPI: | 1437328614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164452115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 PINE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164452115 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 51443-20 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 57.009196 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 35112300 | 05 | WI | MEDICAID |