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General NPI Number Information
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NPI Number | 1336190529
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Entity Type | Individual
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Provider Name | IRENE THOMAS-THEVATHERIL MD
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Gender | Female
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Dates
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Enumeration Date | 05/13/2006
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Last Update Date | 03/22/2021
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Provider Practice Location Address
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Address Line | 3080 OGDEN AVE STE 204
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City | LISLE
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State | IL
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Zip | 60532-1694
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Country | US
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Telephone | 630-734-0580
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Fax | 630-734-0581
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Provider Business Mailing Address
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Address Line | PO BOX 534
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City | LISLE
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State | IL
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Zip | 60532-0534
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Country | US
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Telephone | 630-734-0580
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Fax | 630-734-0581
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 36105417
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License Number State | IL
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