MEDICARE: TIMOTHY JOSEPH PHALEN MD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	35076229P	OH
2	2085R0204X	Vascular & Interventional Radiology Physician	35.076229	OH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1366446148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JOSEPH PHALEN MD

Provider Business Mailing Address
First Line	:	1331 N ELM ST
Second Line	:	SUITE 200
City	:	GREENSBORO
State	:	NC
Zip	:	27401-6302
Country	:	US
Telephone Number	:	336-274-9617
Fax Number	:	336-482-2177

Provider Business Practice Location Address
First Line	:	3000 MACK RD
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-5335
Country	:	US
Telephone Number	:	513-870-7024
Fax Number	:	513-965-8091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	09/28/2021

3000 MACK RD STE 100
FAIRFIELD, OH
45014-5335

Practice Phone: 513-751-4222
Practice Fax: 513-874-3023