MEDICARE: MR. TIM MARK HANNAH

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	320800000X	Mental Illness Community Based Residential Treatment Facility	BH-2721	AZ

General Provider Information

NPI Number	:	1790961233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIM MARK HANNAH

Provider Business Mailing Address
First Line	:	4901 W CALLE DON ALFONSO
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-1422
Country	:	US
Telephone Number	:	520-248-8838
Fax Number	:

Provider Business Practice Location Address
First Line	:	4901 W CALLE DON ALFONSO
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-1422
Country	:	US
Telephone Number	:	520-248-8838
Fax Number	:

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

Provider Enumeration Date	:	01/15/2008
Last Update Date	:	01/15/2008

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