Provider Demographics
NPI:1629037031
Name:HEINLEY, TIMOTHY M (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:HEINLEY
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:MCCANNEL HALL ROOM 100
Mailing Address - Street 2:2891 2ND AVENUE NORTH STOP 9038
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-9038
Mailing Address - Country:US
Mailing Address - Phone:701-777-4500
Mailing Address - Fax:701-777-4835
Practice Address - Street 1:MCCANNEL HALL ROOM 100
Practice Address - Street 2:2891 2ND AVENUE NORTH STOP 9038
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-9038
Practice Address - Country:US
Practice Address - Phone:701-777-4500
Practice Address - Fax:701-777-4835
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16444Medicaid
NDE88343Medicare UPIN
ND11909Medicare ID - Type Unspecified