Healthcare Provider Details

I. General information

NPI: 1962135749
Provider Name (Legal Business Name): TIMOTHY JOSEPH MARCINIAK H.I.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 S KOELLER ST
OSHKOSH WI
54902-5546
US

IV. Provider business mailing address

384 S KOELLER ST
OSHKOSH WI
54902-5546
US

V. Phone/Fax

Practice location:
  • Phone: 920-233-3307
  • Fax:
Mailing address:
  • Phone: 920-233-3307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1655-60
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: