MEDICARE: DR. TIMOTHY J. BLY D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038005081	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05715393	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1841299815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY J. BLY D.C.

Provider Business Mailing Address
First Line	:	2501 E COLLEGE AVE
Second Line	:	STE C
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-2484
Country	:	US
Telephone Number	:	309-585-0704
Fax Number	:	309-661-1043

Provider Business Practice Location Address
First Line	:	2501 E COLLEGE AVE
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-2484
Country	:	US
Telephone Number	:	309-661-1155
Fax Number	:	309-661-1043

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	01/10/2020

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