Provider Demographics
NPI:1841454857
Name:HALT, TIMOTHY PHILIP (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:PHILIP
Last Name:HALT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 W POLK ST
Mailing Address - Street 2:STATION A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4352
Mailing Address - Country:US
Mailing Address - Phone:312-423-4200
Mailing Address - Fax:
Practice Address - Street 1:1634 W POLK ST
Practice Address - Street 2:STATION A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4352
Practice Address - Country:US
Practice Address - Phone:312-423-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124084208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20015920Medicaid