Provider Demographics
NPI:1396838306
Name:DONNELLY, TIMOTHY E (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:1275 N CONVENT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-8210
Practice Address - Country:US
Practice Address - Phone:815-936-1855
Practice Address - Fax:815-936-6097
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00348940Medicare PIN
ILK33302Medicare PIN