Provider Demographics
NPI:1427088061
Name:WOLLNER, TIMOTHY S (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:WOLLNER
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 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-425-9550
Mailing Address - Fax:708-229-6084
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-425-9550
Practice Address - Fax:708-229-6084
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073267Medicaid
IL080055203OtherRAILROAD MEDICARE
C37720Medicare UPIN
IL080055203OtherRAILROAD MEDICARE
IL729903018Medicare PIN