Healthcare Provider Details

I. General information

NPI: 1245223130
Provider Name (Legal Business Name): TIMOTHY M LAHOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 400
PEORIA IL
61614-5021
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 400
PEORIA IL
61614-5021
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-0909
  • Fax: 309-689-3434
Mailing address:
  • Phone: 309-689-0909
  • Fax: 309-689-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036089054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: