Provider Demographics
NPI:1689675811
Name:FENDON, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:FENDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-545-6016
Mailing Address - Fax:
Practice Address - Street 1:2100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5487
Practice Address - Country:US
Practice Address - Phone:815-999-3201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098625207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200895510Medicaid
IL036098625Medicaid
IN000000365227OtherANTHEM
IN200895510Medicaid
IN266540TMedicare PIN
ILL86349Medicare ID - Type Unspecified