Provider Demographics
NPI:1629718879
Name:SCHAEFER, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SCHAEFER
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 1:475 JOHELIA TRL
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-2507
Mailing Address - Country:US
Mailing Address - Phone:847-502-2376
Mailing Address - Fax:
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025276363L00000X
IL041.471722163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse