Basic Information
| Provider Information | |||||||||
| NPI: | 1407290588 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056100 | ||||||||
| FaxNumber: | 4148056147 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056100 | ||||||||
| FaxNumber: | 4148056147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 81028 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 81028 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1407290588 | 05 | WI | MEDICAID |