Basic Information
| Provider Information | |||||||||
| NPI: | 1730187790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILLEEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 SUITE 305 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4606 GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029372209 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 25892 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 64258924 | 05 | KY | MEDICAID | K307890 | 01 | KY | MEDICARE PTAN | OTHER | 021102300 | 01 | FEDERAL BLACK LUNG | OTHER | 2432232000 | 01 | PASSPORT ADVANTAGE | OTHER | 200240660A | 05 | IN | MEDICAID | 000000047638 | 01 | ANTHEM | OTHER | 1048815 | 01 | PASSPORT | OTHER | 611001258 | 01 | HUMANA | OTHER |