Provider Demographics
NPI:1962418103
Name:RUSSELL, TIMOTHY J (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:RUSSELL
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 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7581
Practice Address - Country:US
Practice Address - Phone:708-406-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0685741207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE18589Medicare UPIN