Provider Demographics
NPI:1275976086
Name:MAHER, TIMOTHY JAMES
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:MAHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-948-7385
Mailing Address - Fax:
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:414-389-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63558207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042545Medicaid