Provider Demographics
NPI:1912169764
Name:PROVIAS, TIM S (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:S
Last Name:PROVIAS
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 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-2458
Mailing Address - Fax:312-695-0063
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:GALTER 19-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-2458
Practice Address - Fax:312-695-0063
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129441207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT887ZMedicare PIN