Basic Information
| Provider Information | |||||||||
| NPI: | 1003802141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PLANK | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16600 W SPRAGUE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408260500 | ||||||||
| FaxNumber: | 4408260501 | ||||||||
| Practice Location | |||||||||
| Address1: | 10325 DEWHURST RD | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404149260 | ||||||||
| FaxNumber: | 4403658826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34004783 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0860564 | 05 | OH | MEDICAID |