Provider Demographics
NPI:1629083431
Name:BETH, TIMOTHI J (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHI
Middle Name:J
Last Name:BETH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 MAINE ST STE 48-207
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5875
Mailing Address - Country:US
Mailing Address - Phone:217-214-6213
Mailing Address - Fax:217-214-5848
Practice Address - Street 1:4800 MAINE ST STE 48-207
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5875
Practice Address - Country:US
Practice Address - Phone:217-214-6213
Practice Address - Fax:217-214-5848
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-097195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097195Medicaid
ILF400295080Medicare PIN
IL036097195Medicaid