Basic Information
| Provider Information | |||||||||
| NPI: | 1700992294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'LEARY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11475 OLDE CABIN RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631417129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149918210 | ||||||||
| FaxNumber: | 3149918206 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 US HIGHWAY 61 | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630284124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369330303 | ||||||||
| FaxNumber: | 6369330293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 102187 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 036095208 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 204995302 | 05 | MO | MEDICAID |