=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427040542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY J CASEY D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 04/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1790 NATIONS DR STE 106
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-9175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-360-1330
-----------------------------------------------------
Fax | 847-360-9271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1790 NATIONS DR STE 106
-----------------------------------------------------
City | GURNEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60031-9175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-360-1330
-----------------------------------------------------
Fax | 847-360-9271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016004717
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------