Provider Demographics
NPI:1518113067
Name:WALLER, THOMAS
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 162ND ST
Mailing Address - Street 2:SUITE 522
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:773-895-3921
Mailing Address - Fax:708-575-0432
Practice Address - Street 1:430 E 162ND ST
Practice Address - Street 2:SUITE 522
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2258
Practice Address - Country:US
Practice Address - Phone:773-895-3921
Practice Address - Fax:708-575-0432
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW46082583086172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver