Provider Demographics
NPI:1205852936
Name:THORNTON, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:THORNTON
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 1:234 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-9203
Mailing Address - Country:US
Mailing Address - Phone:989-275-1200
Mailing Address - Fax:989-275-1210
Practice Address - Street 1:234 LAKE ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-9203
Practice Address - Country:US
Practice Address - Phone:989-275-1200
Practice Address - Fax:989-275-1210
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4112847Medicaid
MI4154346Medicaid
MI4154346Medicaid
M61000006Medicare PIN
G93667Medicare UPIN