Provider Demographics
NPI:1235504572
Name:KELLY, TIMOTHY JOSEPH JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH JOHNSON
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:JOSEPH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 E HURON ST
Mailing Address - Street 2:SUITE 1-200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST
Practice Address - Street 2:SUITE 1-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-12
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program