1871752428 NPI number — TIMOTHY WHITEHEAD MD

Table of content: TIMOTHY WHITEHEAD MD (NPI 1871752428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871752428 NPI number — TIMOTHY WHITEHEAD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITEHEAD
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871752428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 OAKWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61611-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-740-4272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 NE GLEN OAK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61637-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-655-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  35.123822 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 82252 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 35.123822 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 036-132985 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0104941 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35.123822 . This is a "LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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