Basic Information
| Provider Information | |||||||||
| NPI: | 1457597106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMM | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 RIVERSIDE DR | ||||||||
| Address2: | SUITE M08 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077237454 | ||||||||
| FaxNumber: | 6077231567 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 RIVERSIDE DR | ||||||||
| Address2: | SUITE M08 | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139054176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077237454 | ||||||||
| FaxNumber: | 6077231567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2008 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | AN006710 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3608100 | 05 | FL | MEDICAID |