Provider Demographics
NPI:1760795801
Name:TIMOTHY G MCNALLY DO PC
Entity Type:Organization
Organization Name:TIMOTHY G MCNALLY DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-743-3937
Mailing Address - Street 1:3364 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1458
Mailing Address - Country:US
Mailing Address - Phone:810-743-3937
Mailing Address - Fax:810-743-9210
Practice Address - Street 1:3364 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1458
Practice Address - Country:US
Practice Address - Phone:810-743-3937
Practice Address - Fax:810-743-9210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITM012077207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3391829Medicaid
MI0B50586OtherBCBS
MI3391829Medicaid
MIG48259Medicare UPIN
MI4600940001Medicare NSC