Basic Information
| Provider Information | |||||||||
| NPI: | 1750385357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17310 WRIGHT ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8332286889 | ||||||||
| FaxNumber: | 8778530376 | ||||||||
| Practice Location | |||||||||
| Address1: | 17310 WRIGHT ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8332286889 | ||||||||
| FaxNumber: | 8778530376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 15495 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11756C | WY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 15891 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0119966000 | 05 | WV | MEDICAID | 0130753 | 01 | WV | UMWA | OTHER | 020011800 | 01 | WV | FEDERAL BLACK LUNG | OTHER | 14175 | 05 | WV | MEDICAID | 55-0516458 | 01 | WV | GROUP FEIN # | OTHER | 550516458 | 01 | WV | ACORDIA NATIONAL PEIA | OTHER | 64942105 | 05 | KY | MEDICAID | F23457 | 01 | WV | BRICKSTREET INSURANCE | OTHER | 000034924 | 01 | WV | FREEDOM BLUE & MS BCBS | OTHER | 151237200 | 01 | WV | US DOL & US POSTAL COMP | OTHER | 2047190 | 05 | OH | MEDICAID | 14193 | 01 | WV | CARELINK & CARELINK PEIA | OTHER | 550516458 | 05 | WV | MEDICAID |