Provider Demographics
NPI:1003929308
Name:VYROSTEK, TIMOTHY B (DC CCSP)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:B
Last Name:VYROSTEK
Suffix:
Gender:M
Credentials:DC CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10633 STATE HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-3225
Mailing Address - Country:US
Mailing Address - Phone:814-382-1970
Mailing Address - Fax:814-382-3619
Practice Address - Street 1:10633 STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-3225
Practice Address - Country:US
Practice Address - Phone:814-382-1970
Practice Address - Fax:814-382-3619
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007097L111N00000X
PA4038111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016549110004Medicaid
PA961159OtherBCBS
PA205055OtherUPMC
PA000232Medicare ID - Type Unspecified
PA205055OtherUPMC