Provider Demographics
NPI:1124003439
Name:PENN, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:PENN
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 1:4802 S STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1904
Mailing Address - Country:US
Mailing Address - Phone:618-288-4388
Mailing Address - Fax:618-288-4927
Practice Address - Street 1:4802 S STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1904
Practice Address - Country:US
Practice Address - Phone:618-288-4388
Practice Address - Fax:618-288-4927
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092240207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092240Medicaid
ILF44766Medicare UPIN
ILK16477Medicare ID - Type Unspecified