Provider Demographics
NPI:1053483362
Name:TYMOCZKO, ROBERT GORDON (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GORDON
Last Name:TYMOCZKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 RUGH ST.
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-5684
Mailing Address - Country:US
Mailing Address - Phone:724-836-8400
Mailing Address - Fax:
Practice Address - Street 1:545 RUGH ST.
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-5684
Practice Address - Country:US
Practice Address - Phone:724-836-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022676E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10937953OtherCAQH
PA0009827020001Medicaid
PA0009827020001Medicaid
B40789Medicare UPIN