Basic Information
| Provider Information | |||||||||
| NPI: | 1821225368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 PINE GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453404500 | ||||||||
| FaxNumber: | 8453404501 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 PINE GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453404500 | ||||||||
| FaxNumber: | 8453404501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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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 | 2085R0202X | 279192 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04181435 | 05 | NY | MEDICAID |