Provider Demographics
NPI:1801013057
Name:THOMAS J. BOYSEN, D.P.M., S.C.
Entity Type:Organization
Organization Name:THOMAS J. BOYSEN, D.P.M., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOYSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-444-0646
Mailing Address - Street 1:16325 HARLEM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2509
Mailing Address - Country:US
Mailing Address - Phone:708-444-0646
Mailing Address - Fax:708-444-1506
Practice Address - Street 1:16325 HARLEM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2509
Practice Address - Country:US
Practice Address - Phone:708-444-0646
Practice Address - Fax:708-444-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002685261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1336119445OtherNPI NON CORPORATE
IL4735590001Medicare NSC
ILT36917Medicare UPIN
IL480029273Medicare ID - Type UnspecifiedRAILROAD MEDICARE
ILK37348Medicare PIN