Healthcare Provider Details

I. General information

NPI: 1316118896
Provider Name (Legal Business Name): ANTOINETTE BENITA THOMAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2040
  • Fax: 847-733-5315
Mailing address:
  • Phone: 847-570-2040
  • Fax: 847-733-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number036120593
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036120593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: