Healthcare Provider Details

I. General information

NPI: 1215963202
Provider Name (Legal Business Name): TIMOTHY EARL KING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11456 BROADWAY
CROWN POINT IN
46307-7106
US

IV. Provider business mailing address

425 JOLIET ST SUITE 400
DYER IN
46311-1765
US

V. Phone/Fax

Practice location:
  • Phone: 219-488-0154
  • Fax: 219-661-1408
Mailing address:
  • Phone: 219-488-0165
  • Fax: 219-865-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036097585
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number01025676A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number01025676A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: