Provider Demographics
NPI:1114950326
Name:MISSBACH, TIMM SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:TIMM
Middle Name:SCOTT
Last Name:MISSBACH
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 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6089
Mailing Address - Country:US
Mailing Address - Phone:920-430-4585
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6089
Practice Address - Country:US
Practice Address - Phone:920-430-4585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38166208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32284100Medicaid
WI072250002Medicare Oscar/Certification
WI075100116Medicare Oscar/Certification
G40093Medicare UPIN
WI430600030Medicare Oscar/Certification
07125-0122Medicare ID - Type Unspecified