Provider Demographics
NPI:1518935972
Name:FITZGERALD, TIMOTHY LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LOUIS
Last Name:FITZGERALD
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 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:887 CONGRESS ST SUITE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:207-774-9388
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21384208600000X
NC2008-014132086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400354421Medicare PIN
MEE400354419Medicare PIN
MI0D16117006Medicare PIN
NC1518935972Medicaid
NC2759308Medicare PIN
NC2759308AMedicare PIN
MI0D16117OtherBCBS
MIH74049Medicare UPIN