Provider Demographics
NPI:1053904896
Name:SIMIC, TIMOTHY ROBERT (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:SIMIC
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 ORMOND RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1903
Mailing Address - Country:US
Mailing Address - Phone:502-558-9325
Mailing Address - Fax:
Practice Address - Street 1:1357 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1353
Practice Address - Country:US
Practice Address - Phone:502-897-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1102450163WE0003X
KY3015217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100571750Medicaid