MEDICARE: MR. THOMAS J. AFRICANO C.R.N.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	209003144	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	430004550	OTHER	IL	PALMETTO GBA/ RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	363175240	OTHER	IL	TAX I.D.
3	1617253	OTHER	IL	BCBS PROVIDER ID
4	0004241899	OTHER	IL	AETNA PIN

General Provider Information

NPI Number	:	1750393328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS J. AFRICANO C.R.N.A.

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-0158
Country	:	US
Telephone Number	:	708-798-5838
Fax Number	:	708-798-5865

Provider Business Practice Location Address
First Line	:	19624 GOVERNORS HWY
Second Line	:
City	:	FLOSSMOOR
State	:	IL
Zip	:	60422-2077
Country	:	US
Telephone Number	:	708-798-5838
Fax Number	:	708-798-5865

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	01/09/2008

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