Provider Demographics
NPI:1023085628
Name:CROSSETT, TIMOTHY RAY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RAY
Last Name:CROSSETT
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:PO BOX 11955
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0132
Mailing Address - Country:US
Mailing Address - Phone:731-541-5000
Mailing Address - Fax:614-210-1886
Practice Address - Street 1:620 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-541-6174
Practice Address - Fax:731-425-6274
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN199522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3058645OtherBCBS
4102190OtherBCBS
TN3086620Medicaid
P00271014OtherRR MEDICARE
TN300056937OtherRR MEDICARE
300056951OtherRR MEDICARE
TN3086628Medicaid
TN3828137Medicaid
TN3086620Medicaid
TN3086628Medicare PIN
TN3086620Medicare PIN
TN300056937OtherRR MEDICARE