Provider Demographics
NPI:1962410829
Name:REARDEN, TIMOTHY P (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:P
Last Name:REARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8056
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:800-647-2098
Mailing Address - Fax:314-362-3192
Practice Address - Street 1:1255 GRAHAM RD
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE 101
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8014
Practice Address - Country:US
Practice Address - Phone:800-647-2098
Practice Address - Fax:314-362-3192
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR2H83207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207853003Medicaid
005011682Medicare ID - Type Unspecified
29352OtherBCBS
F89054Medicare UPIN
MO207853003Medicaid