Provider Demographics
NPI:1841299815
Name:BLY, TIMOTHY J (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:BLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E COLLEGE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2484
Mailing Address - Country:US
Mailing Address - Phone:309-585-0704
Mailing Address - Fax:309-661-1043
Practice Address - Street 1:2501 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2484
Practice Address - Country:US
Practice Address - Phone:309-661-1155
Practice Address - Fax:309-661-1043
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05715393OtherBCBS
IL741580Medicare ID - Type Unspecified
IL350011538Medicare ID - Type UnspecifiedMEDICARE RAILROAD