Healthcare Provider Details

I. General information

NPI: 1770526071
Provider Name (Legal Business Name): GARY D THAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ASTELLAS WAY
NORTHBROOK IL
60062-6111
US

IV. Provider business mailing address

1 ASTELLAS WAY
NORTHBROOK IL
60062-6111
US

V. Phone/Fax

Practice location:
  • Phone: 224-205-5278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number77798
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number77798
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: