Healthcare Provider Details

I. General information

NPI: 1457535759
Provider Name (Legal Business Name): TIMOTHY MORAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 WICKER AVE
SAINT JOHN IN
46373-9487
US

IV. Provider business mailing address

9660 WICKER AVE
SAINT JOHN IN
46373-9487
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-1177
  • Fax: 219-703-6662
Mailing address:
  • Phone: 219-365-1177
  • Fax: 219-703-6662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01100565A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-076975
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: