Provider Demographics
NPI:1669528428
Name:HOLLISTER, TIMOTHY C (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:HOLLISTER
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 1:3201 OLD GLENVIEW RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2964
Mailing Address - Country:US
Mailing Address - Phone:847-512-1849
Mailing Address - Fax:847-512-1850
Practice Address - Street 1:3201 OLD GLENVIEW RD STE 100
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2964
Practice Address - Country:US
Practice Address - Phone:847-512-1849
Practice Address - Fax:847-512-1850
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1046622085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104662Medicaid
IL036104662Medicaid
ILH51118Medicare UPIN
ILP00783512Medicare PIN