Healthcare Provider Details

I. General information

NPI: 1699896431
Provider Name (Legal Business Name): TIMOTHY W PORCELLI LCPED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 N SOUTHPORT
CHICAGO IL
60613-3718
US

IV. Provider business mailing address

POB 13377
CHICAGO IL
60613
US

V. Phone/Fax

Practice location:
  • Phone: 312-409-2175
  • Fax:
Mailing address:
  • Phone: 312-409-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: