Provider Demographics
NPI:1710965223
Name:VONGILLERN, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:VONGILLERN
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 1:520 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6194
Mailing Address - Country:US
Mailing Address - Phone:309-762-3621
Mailing Address - Fax:309-762-3690
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6152
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062158207XS0106X, 207X00000X
IA29517207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1602943OtherFIRST HEALTH
IAP00756425OtherRAILROAD MEDICARE
020376OtherHEALTH ALLIANCE
IA0910729Medicaid
IL8121085OtherBCBS
05283OtherWELLMARK
17658OtherMIDLANDS CHOICE
IL036062158Medicaid
20177OtherIA HEALTH SOLUTIONS
91390OtherWELLMARK
99205OtherWELLMARK
200011702OtherRR MEDICARE
IAIA0189OtherJOHN DEERE FAMILY
ILS50606OtherJOHN DEERE FAMILY
ILS50606OtherJOHN DEERE FAMILY
05283OtherWELLMARK
C44187Medicare UPIN