Provider Demographics
NPI:1124069455
Name:POLAND, TIMOTHY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:POLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1438
Mailing Address - Country:US
Mailing Address - Phone:847-367-2400
Mailing Address - Fax:847-367-2440
Practice Address - Street 1:1162 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1438
Practice Address - Country:US
Practice Address - Phone:847-367-2400
Practice Address - Fax:847-367-2440
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081143Medicaid
IL960010Medicare ID - Type Unspecified