Provider Demographics
NPI:1790752988
Name:LISKE, THOMAS CROSBY (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CROSBY
Last Name:LISKE
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 1:831 SANDHURST DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1390
Mailing Address - Country:US
Mailing Address - Phone:815-786-3060
Mailing Address - Fax:815-786-8701
Practice Address - Street 1:831 SANDHURST DR STE 2
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1186
Practice Address - Country:US
Practice Address - Phone:815-786-3060
Practice Address - Fax:815-786-8701
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042901207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932096OtherBC/BS
IL207RP1001XOtherTAXONOMY
IL3Medicaid
IL1932096OtherBC/BS
IL3Medicaid
ILK35323Medicare PIN