Provider Demographics
NPI:1407833163
Name:ROHDE, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:ROHDE
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 1:3798 E FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5053
Mailing Address - Country:US
Mailing Address - Phone:217-864-2700
Mailing Address - Fax:217-422-3930
Practice Address - Street 1:3798 E FULTON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5053
Practice Address - Country:US
Practice Address - Phone:217-864-2700
Practice Address - Fax:217-422-3930
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081038207Q00000X
CAA46499207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081038Medicaid
ILK39345OtherMEDICARE PROVIDER NUMBER
IL036081038Medicaid