Healthcare Provider Details

I. General information

NPI: 1508956897
Provider Name (Legal Business Name): TIM VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N 4TH ST
CHILLICOTHEE IL
61523-2059
US

IV. Provider business mailing address

319 N 4TH ST
CHILLICOTHEE IL
61523-2059
US

V. Phone/Fax

Practice location:
  • Phone: 309-673-6464
  • Fax: 309-274-3120
Mailing address:
  • Phone: 309-673-6464
  • Fax: 309-274-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-077755
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: