Provider Demographics
NPI:1659423085
Name:THATCH, URSULA LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:LOUISE
Last Name:THATCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:STE 100
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-0060
Mailing Address - Fax:618-288-0063
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:STE 100
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-0060
Practice Address - Fax:618-288-0063
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085831207VG0400X
MO36980207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360858311Medicaid
IL6010076OtherIL-BCBS
IL060-10076OtherIL BCBS
MO1619OtherMO-BCBS-FACET#
ILK48449Medicare PIN
IL0360858311Medicaid