Provider Demographics
NPI:1033371554
Name:THAN, BABY MIN (MD)
Entity Type:Individual
Prefix:
First Name:BABY
Middle Name:MIN
Last Name:THAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7401
Mailing Address - Country:US
Mailing Address - Phone:815-337-7100
Mailing Address - Fax:815-337-8152
Practice Address - Street 1:2000 LAKE AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-337-7100
Practice Address - Fax:815-337-8152
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036134250207Q00000X
IN01070288A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134250OtherSTATE LICENSE
IL036134250Medicaid