Basic Information
Provider Information | |||||||||
NPI: | 1477529873 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOFFMAN | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | RICK | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3180 KETTERING BLVD | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454391924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372930247 | ||||||||
FaxNumber: | 9372930960 | ||||||||
Practice Location | |||||||||
Address1: | 1141 N MONROE DR | ||||||||
Address2: |   | ||||||||
City: | XENIA | ||||||||
State: | OH | ||||||||
PostalCode: | 45385 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373728011 | ||||||||
FaxNumber: | 9373766983 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN144163 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | P00265259 | 01 | OH | RAILROAD MEDICARE | OTHER | 0000000381922 | 01 | OH | ANTHEM | OTHER | 0807014 | 05 | OH |   | MEDICAID |