Provider Demographics
NPI:1740394089
Name:BOESEN, THOMAS P (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:BOESEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:4001 VOLLMER ROAD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461
Practice Address - Country:US
Practice Address - Phone:708-481-8883
Practice Address - Fax:708-481-2917
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060738207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060738Medicaid
160022790OtherR/R MEDICARE
ILK47810Medicare PIN
IL036060738Medicaid
160022790OtherR/R MEDICARE