Provider Demographics
NPI:1073514360
Name:EISEMAN, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:EISEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N. WINFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-933-4700
Mailing Address - Fax:630-933-4721
Practice Address - Street 1:25 N WINFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-933-4700
Practice Address - Fax:630-933-4721
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102548207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherHFS GROUP PAYEE ID
P00884750OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
IL0222075OtherBLUE CROSS GROUP ID
IL036102548Medicaid
IL206147OtherMEDICARE GROUP PTAN
CA4748OtherMEDICARE RAILROAD PTAN (GROUP)
IL1033149844OtherGROUP NPI
ILH57873Medicare UPIN
IL036102548Medicaid