Provider Demographics
NPI:1134388473
Name:PHELAN, TIMOTHY PATRICK (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
Last Name:PHELAN
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 1:3425 EXECUTIVE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3425 EXECUTIVE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1333
Practice Address - Country:US
Practice Address - Phone:567-638-1490
Practice Address - Fax:567-368-1478
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35130966207RC0001X, 207RC0000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD221109200Medicaid
MDS062-0430OtherCAREFIRST BC/BS - REGIONAL
MD974410-01OtherCAREFIRST BC/BS
MD220637Y3WMedicare PIN
MDS062-0430OtherCAREFIRST BC/BS - REGIONAL
MD221109200Medicaid