MEDICARE: TIMOTHY MICHAEL PHELAN M.D.

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	207V00000X	Obstetrics & Gynecology Physician	ME28633	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1639131584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY MICHAEL PHELAN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 25317
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33622-5317
Country	:	US
Telephone Number	:	813-286-0033
Fax Number	:	813-282-1806

Provider Business Practice Location Address
First Line	:	2525 RIVERSIDE AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4710
Country	:	US
Telephone Number	:	904-388-0704
Fax Number	:	904-387-9095

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	02/26/2019

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