Provider Demographics
NPI:1164466058
Name:BALTZ, TIMOTHY S (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:S
Last Name:BALTZ
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 1:1017 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6780
Mailing Address - Country:US
Mailing Address - Phone:334-875-2100
Mailing Address - Fax:334-418-6540
Practice Address - Street 1:1017 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6780
Practice Address - Country:US
Practice Address - Phone:334-875-2100
Practice Address - Fax:334-418-6540
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000114902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL332100111Medicaid
AL51017797OtherBCBS OF ALABAMA
AL332134111Medicaid
AL000017797Medicare ID - Type UnspecifiedMEDICARE PRO.-CAHABA PRO
C75730Medicare UPIN