Healthcare Provider Details

I. General information

NPI: 1053904896
Provider Name (Legal Business Name): TIMOTHY ROBERT SIMIC NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1357 BARDSTOWN RD
LOUISVILLE KY
40204-1353
US

IV. Provider business mailing address

3800 ORMOND RD
LOUISVILLE KY
40207-1903
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-6443
  • Fax:
Mailing address:
  • Phone: 502-558-9325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1102450
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015217
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: