Basic Information
| Provider Information | |||||||||
| NPI: | 1295731602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIERSON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707815111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 484 GOLDEN AUTUMN WAY STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707833340 | ||||||||
| FaxNumber: | 2707800492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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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 | 208600000X | 26264 | KY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 64262645 | 05 | KY | MEDICAID |