Provider Demographics
NPI:1043200686
Name:GORMLEY, TIMOTHY S (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:GORMLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC 1023
Mailing Address - Street 2:P.O. BOX 2300
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210
Mailing Address - Country:US
Mailing Address - Phone:509-946-4611
Mailing Address - Fax:509-943-9272
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:509-946-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0353102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8487944Medicaid
OR274577Medicaid
WA8487944Medicaid
WA8867116Medicare PIN
G15665Medicare UPIN
WAP00416214Medicare PIN