Healthcare Provider Details

I. General information

NPI: 1962852327
Provider Name (Legal Business Name): MELVIN THOMAS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435
US

IV. Provider business mailing address

5126 N KENNETH AVE
CHICAGO IL
60630-2623
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-7133
  • Fax:
Mailing address:
  • Phone: 773-837-2048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOT017294
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036149219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: