Healthcare Provider Details

I. General information

NPI: 1235780263
Provider Name (Legal Business Name): PERIPHERY NEUROPHYSIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 PLEASANT ST
EPPING NH
03042-3512
US

IV. Provider business mailing address

49 PLEASANT ST
EPPING NH
03042-3512
US

V. Phone/Fax

Practice location:
  • Phone: 801-674-9066
  • Fax:
Mailing address:
  • Phone: 801-674-9066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD TIMM
Title or Position: CEO
Credential: CNIM, R. EEG T.
Phone: 801-674-9066