Healthcare Provider Details

I. General information

NPI: 1962709253
Provider Name (Legal Business Name): KORATHU THOMAS, MD, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W DIVISION ST
CHICAGO IL
60622-2717
US

IV. Provider business mailing address

PO BOX 1201
NORTHBROOK IL
60065-1201
US

V. Phone/Fax

Practice location:
  • Phone: 773-227-8870
  • Fax: 312-770-3208
Mailing address:
  • Phone: 773-283-9594
  • Fax: 773-283-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number036053507
License Number StateIL

VIII. Authorized Official

Name: DR. KORATHU THOMAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-283-9594