Healthcare Provider Details

I. General information

NPI: 1982679569
Provider Name (Legal Business Name): TIMOTHY J LAWLESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N 4TH ST
CHILLICOTHEE IL
61523-2058
US

IV. Provider business mailing address

1120 E WAR MEMORIAL DR
PEORIA HEIGHTS IL
61616-7757
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-2108
  • Fax: 309-274-6920
Mailing address:
  • Phone: 309-685-4411
  • Fax: 309-685-0172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098740
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: