Provider Demographics
NPI:1528958121
Name:HEDSTROM, TIMOTHY HAROLD
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:HAROLD
Last Name:HEDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 GLENDA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1020
Mailing Address - Country:US
Mailing Address - Phone:541-680-7063
Mailing Address - Fax:
Practice Address - Street 1:415 GLENDA AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1020
Practice Address - Country:US
Practice Address - Phone:541-680-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
OR229461090343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)