Basic Information
| Provider Information | |||||||||
| NPI: | 1164506788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGONIGLE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT FAGO MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 NATOMA ST | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163558500 | ||||||||
| FaxNumber: | 9163558196 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 NATOMA ST | ||||||||
| Address2: | |||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163558500 | ||||||||
| FaxNumber: | 9163558196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2251X0800X | PT22365 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | ZZZ611242 | 01 | CA | BLUE SHIELD | OTHER | PT10120 | 01 | BLUE CROSS | OTHER |