Provider Demographics
NPI:1760667703
Name:DR. TIMOTHY J. GRAHAM PC
Entity Type:Organization
Organization Name:DR. TIMOTHY J. GRAHAM PC
Other - Org Name:DR. TIMOTHY J. GRAHAM PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-287-7622
Mailing Address - Street 1:708 W SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1200
Mailing Address - Country:US
Mailing Address - Phone:217-287-7622
Mailing Address - Fax:217-287-2274
Practice Address - Street 1:708 W SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1200
Practice Address - Country:US
Practice Address - Phone:217-287-7622
Practice Address - Fax:217-287-2274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. TIMOTHY J GRAHAM PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-09
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003763213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL726760Medicare UPIN
IL5045540001Medicare NSC