Healthcare Provider Details

I. General information

NPI: 1417308925
Provider Name (Legal Business Name): TIMOTHY CRAIG WIRT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 DELNOR DR STE 401
GENEVA IL
60134-4235
US

IV. Provider business mailing address

680 NORTH LAKE SHORE DRIVE
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4056
  • Fax:
Mailing address:
  • Phone: 312-695-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: