Basic Information
Provider Information | |||||||||
NPI: | 1871541375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAMBERLAIN | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1234 E. DUPONT RD. | ||||||||
Address2: | SUITE 3 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468251545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603739700 | ||||||||
FaxNumber: | 2603739740 | ||||||||
Practice Location | |||||||||
Address1: | 344 N. MAIN ST. | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA CITY | ||||||||
State: | IN | ||||||||
PostalCode: | 46725 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2602482575 | ||||||||
FaxNumber: | 2602482726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 03/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1033472 | IN | N |   | Other Service Providers | Specialist |   | 208600000X | 01033472A | IN | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 85760 | 01 | IN | ANTHEM BCBS | OTHER | P00732002 | 01 | IN | RAILROAD MEDICARE | OTHER | 020004909 | 01 | IN | RAILROAD MEDICARE | OTHER | 100263100 | 05 | IN |   | MEDICAID | 000000603874 | 01 | IN | ANTHEM | OTHER |