Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 036-101880 | IL |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 036101880 | IL |
NPI | 1124099809 |
---|---|
Provider Name | Timothy S Petsche |
First Address | Geneva, IL 60134-2578 |
Second Address | Geneva, IL 60134-2578 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 30/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036101880 | (05) | IL |
200038329 | RAILROAD MEDICARE (01) | |
753210 | MEDICARE GROUP (01) | |
CF2064 | RAILROAD GROUP (01) | IL |
H13208 | (02) |