Provider Demographics
NPI:1902838139
Name:THILO, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:THILO
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 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-667-1588
Mailing Address - Fax:208-667-3788
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 304
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-1588
Practice Address - Fax:208-667-3788
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4920208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID020013147OtherRR MEDICARE
WA1014299Medicaid
ID002592200Medicaid
ID49205OtherBC ID
B63755Medicare UPIN
WA1014299Medicaid