Provider Demographics
NPI:1871541375
Name:CHAMBERLAIN, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:CHAMBERLAIN
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 1:1234 E. DUPONT RD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:344 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725
Practice Address - Country:US
Practice Address - Phone:260-248-2575
Practice Address - Fax:260-248-2726
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1033472174400000X
IN01033472A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN85760OtherANTHEM BCBS
INP00732002OtherRAILROAD MEDICARE
IN020004909OtherRAILROAD MEDICARE
IN100263100Medicaid
IN000000603874OtherANTHEM
IN85760OtherANTHEM BCBS
IN070860C2Medicare PIN
IN020004909OtherRAILROAD MEDICARE