Provider Demographics
NPI:1699896431
Name:PORCELLI, TIMOTHY W (LCPED)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:PORCELLI
Suffix:
Gender:M
Credentials:LCPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 13377
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:312-409-2175
Mailing Address - Fax:
Practice Address - Street 1:3723 N SOUTHPORT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3718
Practice Address - Country:US
Practice Address - Phone:312-409-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1670909OtherBLUE CROSS