Healthcare Provider Details

I. General information

NPI: 1255701090
Provider Name (Legal Business Name): AUREA THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 S VINE AVE
PARK RIDGE IL
60068-5421
US

IV. Provider business mailing address

1704 S VINE AVE
PARK RIDGE IL
60068-5421
US

V. Phone/Fax

Practice location:
  • Phone: 847-430-3920
  • Fax:
Mailing address:
  • Phone: 847-430-3920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.134743
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: