Provider Demographics
NPI:1487851283
Name:PRICE, TIMOTHY RAY (CPO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RAY
Last Name:PRICE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1618
Mailing Address - Country:US
Mailing Address - Phone:847-470-1287
Mailing Address - Fax:847-470-1287
Practice Address - Street 1:815 N LARKIN AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3438
Practice Address - Country:US
Practice Address - Phone:815-207-4200
Practice Address - Fax:815-207-4200
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL211-0000251744P3200X, 224P00000X
IL213-000028222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXX-XXX1669Medicaid
IL4699410002Medicare NSC