Provider Demographics
NPI:1508956897
Name:VEGA, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-2059
Mailing Address - Country:US
Mailing Address - Phone:309-673-6464
Mailing Address - Fax:309-274-3120
Practice Address - Street 1:319 N 4TH ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2059
Practice Address - Country:US
Practice Address - Phone:309-673-6464
Practice Address - Fax:309-274-3120
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077755Medicaid
ILR00980OtherMEDICARE INDIVIDUAL #
IL833230OtherMEDICARE GROUP #
IL036077755Medicaid
IL833230OtherMEDICARE GROUP #
IL815950Medicare ID - Type UnspecifiedGROUP #
ILR00980OtherMEDICARE INDIVIDUAL #