Provider Demographics
NPI:1760683155
Name:TIM CONRAD, M.D.
Entity Type:Organization
Organization Name:TIM CONRAD, M.D.
Other - Org Name:CONRAD EYE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-899-7778
Mailing Address - Street 1:PO BOX 6015
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-0015
Mailing Address - Country:US
Mailing Address - Phone:502-899-7778
Mailing Address - Fax:
Practice Address - Street 1:1919 STATE ST STE 210
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6805
Practice Address - Country:US
Practice Address - Phone:502-944-6063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041184207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1225196777OtherIND NPI
IN200261230AMedicaid
KY6429088500Medicaid
KY1225196777OtherIND NPI
IN200261230AMedicaid
KY1225196777OtherIND NPI
INF45451Medicare UPIN