Basic Information
| Provider Information | |||||||||
| NPI: | 1134185341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIMOTHY TOM MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 504738 | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631504738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884477220 | ||||||||
| FaxNumber: | 3368841643 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 GENERAL CAVAZOS BLVD | ||||||||
| Address2: | |||||||||
| City: | KINGSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783637129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615959738 | ||||||||
| FaxNumber: | 3615959695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 01/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | TOM | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8002778151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0006EA | 01 | TX | TEXAS BCBS | OTHER |