Provider Demographics
NPI:1093803777
Name:BROESEKER, TIM ALAN (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:ALAN
Last Name:BROESEKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MICCOSUKEE ROAD
Mailing Address - Street 2:TMPP - CANCER & HEMATOLOGY
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-431-5360
Mailing Address - Fax:850-431-5367
Practice Address - Street 1:1300 MICCOSUKEE ROAD
Practice Address - Street 2:TMPP - CANCER & HEMATOLOGY
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-431-5360
Practice Address - Fax:850-431-5367
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047148207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05945OtherBCBS
FL048530600Medicaid
FL05945Medicare ID - Type Unspecified
D61319Medicare UPIN