Provider Demographics
NPI:1669732723
Name:TATUM, TIMOTHY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:TATUM
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 1:2624 WENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3138
Mailing Address - Country:US
Mailing Address - Phone:502-558-2689
Mailing Address - Fax:
Practice Address - Street 1:9825 KENWOOD RD STE 105
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6252
Practice Address - Country:US
Practice Address - Phone:513-872-4500
Practice Address - Fax:513-527-0416
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH351333812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0280677Medicaid
OHG529780OtherMEDICARE OHIO