Provider Demographics
NPI:1730187790
Name:KILLEEN, TIMOTHY ROBERT (MD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:KILLEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351 SUITE 305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4606 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258
Practice Address - Country:US
Practice Address - Phone:502-937-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25892207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64258924Medicaid
KYK307890OtherMEDICARE PTAN
021102300OtherFEDERAL BLACK LUNG
2432232000OtherPASSPORT ADVANTAGE
IN200240660AMedicaid
000000047638OtherANTHEM
1048815OtherPASSPORT
611001258OtherHUMANA
IN213320AMedicare PIN
KY64258924Medicaid
KY64258924Medicaid