Provider Demographics
NPI:1366446148
Name:PHALEN, TIMOTHY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:PHALEN
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 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-870-7024
Practice Address - Fax:513-965-8091
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076229P2085R0202X
OH35.0762292085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2222893Medicaid
KY64049968Medicaid
IN200276720AMedicaid
KY64049968Medicaid
OHH00977Medicare UPIN
OH300121885Medicare PIN