=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346791977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMOTHY DAILEY DPM PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2016
-----------------------------------------------------
Last Update Date | 01/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7305 MIDLAND RD STE 2
-----------------------------------------------------
City | FREELAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48623-8410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-695-6788
-----------------------------------------------------
Fax | 989-695-6491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4310 LEONARD ST NW SUITE 103
-----------------------------------------------------
City | WALKER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49534-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-453-6329
-----------------------------------------------------
Fax | 616-453-1725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DR. TIMOTHY DAILEY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 989-695-6788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 5901002466
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------