Healthcare Provider Details

I. General information

NPI: 1043215148
Provider Name (Legal Business Name): EUGENE M TANQUILUT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20060 GOVERNORS DR SUITE 102
OLYMPIA FIELDS IL
60461-1029
US

IV. Provider business mailing address

20060 GOVERNORS DR SUITE 102
OLYMPIA FIELDS IL
60461-1029
US

V. Phone/Fax

Practice location:
  • Phone: 815-824-4406
  • Fax: 815-844-0307
Mailing address:
  • Phone: 815-824-4406
  • Fax: 815-844-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number02002492A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036094341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: