Provider Demographics
NPI:1659564730
Name:TIMOTHY E PHELAN, M.D A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TIMOTHY E PHELAN, M.D A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:CREEKSIDE OB/GYN OF FOLSOM MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-984-7428
Mailing Address - Street 1:1621 CREEKSIDE DR
Mailing Address - Street 2:102
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3493
Mailing Address - Country:US
Mailing Address - Phone:916-984-7428
Mailing Address - Fax:916-984-0157
Practice Address - Street 1:1621 CREEKSIDE DR
Practice Address - Street 2:102
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3493
Practice Address - Country:US
Practice Address - Phone:916-984-7428
Practice Address - Fax:916-984-0157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG084901174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG29062Medicare UPIN