Provider Demographics
NPI:1154317907
Name:TANSELLE, TIMOTHY R (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:TANSELLE
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 1:1040 SIERRA DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4284
Mailing Address - Fax:317-865-8355
Practice Address - Street 1:1500 DARLINGTON AVE
Practice Address - Street 2:STE 300
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2057
Practice Address - Country:US
Practice Address - Phone:765-362-4940
Practice Address - Fax:765-362-1302
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028702207Q00000X
IN01028702A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000175365OtherBCBS
IN100185470Medicaid
INM471400010OtherMEDICARE PROVIDER PTAN
IN168070Medicare ID - Type Unspecified
INM471400010OtherMEDICARE PROVIDER PTAN
IN100185470Medicaid