Basic Information
| Provider Information | |||||||||
| NPI: | 1548403231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBILT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082886495 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082886495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2009 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 55868-20 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 17227 | NV | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 102696 | AK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1548403231 | 05 | WI | MEDICAID |