Provider Demographics
NPI:1336245091
Name:GRIESBAUM, TIMOTHY JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:GRIESBAUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 VISA DR
Mailing Address - Street 2:1A
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2137
Mailing Address - Country:US
Mailing Address - Phone:309-268-9888
Mailing Address - Fax:309-268-9887
Practice Address - Street 1:1607 VISA DR
Practice Address - Street 2:1A
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2137
Practice Address - Country:US
Practice Address - Phone:309-268-9888
Practice Address - Fax:309-268-9887
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008016111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5141563OtherAETNA
IL041774OtherHEALTH ALLIANCE
IL296417OtherHEALTHLINK
IL350046480OtherR/R MEDICARE
IL038008016Medicaid
IL05722922OtherBCBS
IL350046480OtherR/R MEDICARE
IL041774OtherHEALTH ALLIANCE