Provider Demographics
NPI:1972191674
Name:ELLISON, TIMOTHY WILLIAM
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 6TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1932
Mailing Address - Country:US
Mailing Address - Phone:218-996-3225
Mailing Address - Fax:
Practice Address - Street 1:306 6TH ST SW
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1932
Practice Address - Country:US
Practice Address - Phone:218-996-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor