Provider Demographics
NPI:1639717234
Name:CROSS, TIMOTHY ALLAN (HIS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLAN
Last Name:CROSS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2956
Mailing Address - Country:US
Mailing Address - Phone:937-717-0694
Mailing Address - Fax:937-717-0862
Practice Address - Street 1:934 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7485
Practice Address - Country:US
Practice Address - Phone:937-402-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02216237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH82-5224411Medicaid