MEDICARE: TIMOTHY TOM MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0006EA	OTHER	TX	TEXAS BCBS

General Provider Information

NPI Number	:	1134185341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY TOM MD PA

Provider Business Mailing Address
First Line	:	P.O. BOX 504738
Second Line	:
City	:	ST. LOUIS
State	:	MO
Zip	:	63150-4738
Country	:	US
Telephone Number	:	888-447-7220
Fax Number	:	336-884-1643

Provider Business Practice Location Address
First Line	:	1311 GENERAL CAVAZOS BLVD
Second Line	:
City	:	KINGSVILLE
State	:	TX
Zip	:	78363-7129
Country	:	US
Telephone Number	:	361-595-9738
Fax Number	:	361-595-9695

Authorized Official
Title or Position	:	OWNER
Name	:	TIMOTHY TOM
Credential	:	MD
Telephone Number	:	800-277-8151

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	01/28/2009

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