Provider Demographics
NPI:1306989066
Name:TIERNEY, TIMOTHY A (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:TIERNEY
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 1:675 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3138
Mailing Address - Country:US
Mailing Address - Phone:781-662-4934
Mailing Address - Fax:781-662-4711
Practice Address - Street 1:675 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3138
Practice Address - Country:US
Practice Address - Phone:781-662-4934
Practice Address - Fax:781-662-4711
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASX0146Medicare UPIN
MAE93302Medicare UPIN