Provider Demographics
NPI:1922032580
Name:HARDER, TIM GILBERT (MD)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:GILBERT
Last Name:HARDER
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:PO BOX 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-431-1970
Practice Address - Street 1:3860 MONROE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8399
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-1970
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28468208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30838700Medicaid
07125-0148Medicare ID - Type Unspecified
B53407Medicare UPIN