Provider Demographics
NPI:1952319550
Name:SALLEY, TIMOTHY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:SALLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 BROADSMORE DR
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-6611
Mailing Address - Country:US
Mailing Address - Phone:847-844-8911
Mailing Address - Fax:
Practice Address - Street 1:1811 BROADSMORE DR
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-6611
Practice Address - Country:US
Practice Address - Phone:847-844-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38848Medicare UPIN
IL1607759Medicare ID - Type Unspecified