Basic Information
| Provider Information | |||||||||
| NPI: | 1477554277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISERI | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 S CARMEL ST | ||||||||
| Address2: | |||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496012547 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 CARMEL ST | ||||||||
| Address2: | |||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496012547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318763876 | ||||||||
| FaxNumber: | 2317751115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD22588 | OR | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | M7982 | ID | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 4301065506 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 288205 | 05 | OR | MEDICAID | 805805300 | 05 | ID | MEDICAID | 020H310060 | 01 | BCBS | OTHER | 4890725 | 05 | MI | MEDICAID |