Basic Information
| Provider Information | |||||||||
| NPI: | 1417980848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THUNDER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 SW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032210161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 SW 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032210161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD22487 | OR | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD22487 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110219893 | 01 | OR | RR MEDICARE - PHS | OTHER | 288357 | 05 | OR | MEDICAID |