Provider Demographics
NPI:1124099809
Name:PETSCHE, TIMOTHY S (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:PETSCHE
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 1:2525 KANEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2578
Mailing Address - Country:US
Mailing Address - Phone:630-584-1400
Mailing Address - Fax:630-584-1733
Practice Address - Street 1:2525 KANEVILLE RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2578
Practice Address - Country:US
Practice Address - Phone:630-584-1400
Practice Address - Fax:630-584-1733
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101880207XX0005X
IL036-101880207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200038329OtherRAILROAD MEDICARE
ILCF2064OtherRAILROAD GROUP
IL036101880Medicaid
753210OtherMEDICARE GROUP
L77556Medicare PIN
ILCF2064OtherRAILROAD GROUP