Basic Information
| Provider Information | |||||||||
| NPI: | 1598706384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LASETER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 RIVER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553818 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 1771 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370434990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315526622 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/02/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1625 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | N0199 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8B8472 | 01 | TX | BCBS | OTHER | 195010702 | 05 | TX | MEDICAID | 8X1238 | 01 | TX | BCBS | OTHER | 195010701 | 05 | TX | MEDICAID | P00651455 | 01 | TX | RAILROAD | OTHER | 3300734 | 05 | TN | MEDICAID |