Healthcare Provider Details

I. General information

NPI: 1255375515
Provider Name (Legal Business Name): TIMOTHY E MORTHLAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DR WARREN TUTTLE DR
HARRISBURG IL
62946-2718
US

IV. Provider business mailing address

PO BOX 159
WEST FRANKFORT IL
62896-0159
US

V. Phone/Fax

Practice location:
  • Phone: 618-253-7671
  • Fax:
Mailing address:
  • Phone: 618-218-3560
  • Fax: 618-551-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-114335
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: