Provider Demographics
NPI:1467441873
Name:SORG, TIMOTHY BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRUCE
Last Name:SORG
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 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2640
Mailing Address - Country:US
Mailing Address - Phone:937-245-7150
Mailing Address - Fax:866-527-1320
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415
Practice Address - Country:US
Practice Address - Phone:937-279-5803
Practice Address - Fax:937-279-5803
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053064207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0833674Medicaid
E76229Medicare UPIN
OH0833674Medicaid