Healthcare Provider Details

I. General information

NPI: 1861425902
Provider Name (Legal Business Name): TIMOTHY R EDISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

IV. Provider business mailing address

100 THEDA CLARK MEDICAL PLZ STE 400
NEENAH WI
54956-2763
US

V. Phone/Fax

Practice location:
  • Phone: 920-725-4527
  • Fax: 920-729-2378
Mailing address:
  • Phone: 920-725-4527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036078276
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number37531
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: