Healthcare Provider Details

I. General information

NPI: 1952833154
Provider Name (Legal Business Name): THOMAS KLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

10736 LOREL AVE
OAK LAWN IL
60453-5065
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-1600
  • Fax:
Mailing address:
  • Phone: 708-539-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: