Provider Demographics
NPI:1508822792
Name:BROACH, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:BROACH
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD # UH3005
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-962-8851
Practice Address - Fax:317-962-5957
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061214A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200534140Medicaid
INP00321667Medicare PIN
IN165460KKKKMedicare PIN
INP00886801Medicare PIN
IN267030SMedicare PIN
IN200534140Medicaid