Healthcare Provider Details

I. General information

NPI: 1679079586
Provider Name (Legal Business Name): TIMOTHY G KISCOE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 STATE RD
CINCINNATI OH
45255-2439
US

IV. Provider business mailing address

4921 RELLEUM AVE
CINCINNATI OH
45238-3805
US

V. Phone/Fax

Practice location:
  • Phone: 513-624-4500
  • Fax:
Mailing address:
  • Phone: 859-803-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number308963
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019711
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: