Basic Information
| Provider Information | |||||||||
| NPI: | 1639254709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCUE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629D LOWTHER RD | ||||||||
| Address2: | |||||||||
| City: | LEWISBERRY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173399527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 41 WILDGROUND LN | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598023335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065878631 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 207QS0010X | 10429 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 2085R0202X | DR.0040843 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207Q00000X | 10429 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0202X | MED-PHYS-LIC-10429 | MT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD466135 | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 26579774 | 05 | CO | MEDICAID |