Provider Demographics
NPI:1144214180
Name:HANLEY, TIMOTHY B (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:B
Last Name:HANLEY
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 1:3830 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8153
Mailing Address - Country:US
Mailing Address - Phone:231-929-3888
Mailing Address - Fax:231-929-4365
Practice Address - Street 1:3830 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8153
Practice Address - Country:US
Practice Address - Phone:231-929-3888
Practice Address - Fax:231-929-4365
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048021207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1020070001OtherDMERC REG B
MI180018787OtherRAILROAD MEDICARE
MI180B86357OtherBLUE CROSS BLUE SHIELD
MI103164508Medicaid
MI0B86357001Medicare PIN
MI180018787OtherRAILROAD MEDICARE
MI180B86357OtherBLUE CROSS BLUE SHIELD