Provider Demographics
NPI:1598767410
Name:THOMPSON, TREVONNE M (MD)
Entity Type:Individual
Prefix:
First Name:TREVONNE
Middle Name:M
Last Name:THOMPSON
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 1:808 S WOOD ST
Mailing Address - Street 2:MC724
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7300
Mailing Address - Country:US
Mailing Address - Phone:312-355-0445
Mailing Address - Fax:
Practice Address - Street 1:808 S WOOD ST
Practice Address - Street 2:MC724
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7300
Practice Address - Country:US
Practice Address - Phone:312-355-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112845207P00000X
IL036-112845207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112845Medicaid
IL036112845Medicaid