Basic Information
| Provider Information | |||||||||
| NPI: | 1073600987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANBORN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK CREEK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531542010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143468000 | ||||||||
| FaxNumber: | 4143468010 | ||||||||
| Practice Location | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626533650 | ||||||||
| FaxNumber: | 2626563672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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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 | 207RC0000X | 036102493 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 69326 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1073600987 | 05 | WI | MEDICAID |