1174803050 NPI number — MR. TIMOTHY J LOERKE PA-C

Table of content: MR. TIMOTHY J LOERKE PA-C (NPI 1174803050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174803050 NPI number — MR. TIMOTHY J LOERKE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOERKE
Provider First Name:
TIMOTHY
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174803050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MISSOURI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-293-5335
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13151 MAGISTERIAL DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40223-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-587-1236
Provider Business Practice Location Address Fax Number:
502-587-0126
Provider Enumeration Date:
08/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA1785 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 10002494A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA07315 . This is a "TEXAS STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PA1785 . This is a "KENTUCKY STATE LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1098783 . This is a "NCCPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 288231801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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