Healthcare Provider Details

I. General information

NPI: 1497793400
Provider Name (Legal Business Name): DIABETES THYROID AND OSTEOPOROSIS CLINIC OF SOUTHERN ILLINOIS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOLLY RIDGE CT
SWANSEA IL
62226
US

IV. Provider business mailing address

1 HOLLY RIDGE CT
SWANSEA IL
62226-2322
US

V. Phone/Fax

Practice location:
  • Phone: 618-520-3003
  • Fax: 618-277-3926
Mailing address:
  • Phone: 618-520-3003
  • Fax: 618-277-3926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number042616864
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS F TSE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-520-3003