MEDICARE: DR. TIMOTHY J LAWLESS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036098740	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982679569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY J LAWLESS M.D.

Provider Business Mailing Address
First Line	:	1120 E WAR MEMORIAL DR
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7757
Country	:	US
Telephone Number	:	309-685-4411
Fax Number	:	309-685-0172

Provider Business Practice Location Address
First Line	:	210 N 4TH ST
Second Line	:
City	:	CHILLICOTHEE
State	:	IL
Zip	:	61523-2058
Country	:	US
Telephone Number	:	309-274-2108
Fax Number	:	309-274-6920

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	04/09/2012

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