Provider Demographics
NPI:1194723247
Name:WILLIAMS, TIMOTHY R (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WEST STATE ST.
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-7242
Mailing Address - Fax:
Practice Address - Street 1:2200 STATE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-1852
Practice Address - Country:US
Practice Address - Phone:618-943-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001015AB207PE0004X
IL036.120252207L00000X
IN02001015A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245815311Medicaid
E41093Medicare UPIN
E41093Medicare UPIN