Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 01068721A | IN |
N | 207Q00000X | Family Doctor | 036-121122 | IL |
Y | 207QS0010X | Family Doctor - Sports Medicine | 01068721A | IN |
N | 207QS0010X | Family Doctor - Sports Medicine | 036-121122 | IL |
NPI | 1154461739 |
---|---|
Provider Name | Dr. Timothy James Von Fange |
First Address | Chicago, IL 60677-5383 |
Second Address | Columbus, IN 47203-4427 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2007 |
Last Update Date | 28/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036121122 | (05) | IL |