Provider Demographics
NPI:1194720870
Name:GRUBE, TIMOTHY GUY (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:GUY
Last Name:GRUBE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 S BALLIET ST
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-2105
Mailing Address - Country:US
Mailing Address - Phone:570-874-3404
Mailing Address - Fax:570-874-1491
Practice Address - Street 1:219 S BALLIET ST
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931-2105
Practice Address - Country:US
Practice Address - Phone:570-874-3404
Practice Address - Fax:570-874-1491
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009280L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018174270002Medicaid
PA038135JPUMedicare PIN
PAH16483Medicare UPIN