Healthcare Provider Details

I. General information

NPI: 1154367639
Provider Name (Legal Business Name): EDWARD TONG M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E BURLINGTON ST
RIVERSIDE IL
60546-2146
US

IV. Provider business mailing address

105 E BURLINGTON ST
RIVERSIDE IL
60546-2382
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-0333
  • Fax: 708-442-9863
Mailing address:
  • Phone: 708-442-0333
  • Fax: 708-442-9863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036084251
License Number StateIL

VIII. Authorized Official

Name: DR. EDWARD TONG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-442-0333