Provider Demographics
NPI:1134213119
Name:GRAHAM, TIMOTHY J (DPM)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:GRAHAM
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 1:708 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003763213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL726760Medicare PIN
ILT38204Medicare UPIN
IL1134213119Medicare NSC