Provider Demographics
NPI:1598706871
Name:WESTERHOFF, THOMAS ROY (M D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROY
Last Name:WESTERHOFF
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2809
Mailing Address - Country:US
Mailing Address - Phone:217-222-5055
Mailing Address - Fax:217-222-6536
Practice Address - Street 1:1121 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2809
Practice Address - Country:US
Practice Address - Phone:217-222-5055
Practice Address - Fax:217-222-6536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00410Medicaid
IL37107361862301A001OtherCHAMPUS ID
IL0000100276OtherBLUESHIELD ID
ILC37300Medicare UPIN
IL0000100276OtherBLUESHIELD ID