Provider Demographics
NPI:1699859785
Name:BURK, TIMOTHY (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:BURK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 POLAND MNR
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2010
Mailing Address - Country:US
Mailing Address - Phone:330-757-1815
Mailing Address - Fax:
Practice Address - Street 1:1677 STATE ROUTE 65
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117
Practice Address - Country:US
Practice Address - Phone:724-752-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007683L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA851603OtherHIGHMARK
PA0072326060002Medicaid
PA0072326060002Medicaid