Provider Demographics
NPI:1407814916
Name:WELLEMEYER, TIMOTHY T (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:T
Last Name:WELLEMEYER
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 1:4378 HOLT RD
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1666
Mailing Address - Country:US
Mailing Address - Phone:517-694-1466
Mailing Address - Fax:517-694-3530
Practice Address - Street 1:4378 HOLT RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1666
Practice Address - Country:US
Practice Address - Phone:517-694-1466
Practice Address - Fax:517-694-3530
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITW044920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TW044920OtherBCBSM
MI0100235OtherPHYSICIANS HEALTH PLAN OF
MI102805476Medicaid
TW044920OtherBCN BLUE CARE NETWORK
MI0170235OtherPHYSICIANS HEALTH PLAN OF
TW044920OtherBCBSM
B46440Medicare UPIN
C36477003Medicare ID - Type Unspecified