Healthcare Provider Details

I. General information

NPI: 1457565475
Provider Name (Legal Business Name): HERMON TONEY III CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6937 S CONSTANCE AVE
CHICAGO IL
60649-1507
US

IV. Provider business mailing address

6937 S CONSTANCE AVE
CHICAGO IL
60649-1507
US

V. Phone/Fax

Practice location:
  • Phone: 312-925-3260
  • Fax:
Mailing address:
  • Phone: 312-925-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number238000006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: