Provider Demographics
NPI:1407849706
Name:THALLER, TIMOTHY R (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:THALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:614 E GRADY ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2067
Mailing Address - Country:US
Mailing Address - Phone:912-764-9001
Mailing Address - Fax:912-764-3166
Practice Address - Street 1:614 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2067
Practice Address - Country:US
Practice Address - Phone:912-764-9001
Practice Address - Fax:912-764-3166
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA046818208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000829507BMedicaid
GA340016471OtherRR MEDICARE
GA782637OtherBCBS