Provider Demographics
NPI:1639211386
Name:MAIBENCO, THOMAS A (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:MAIBENCO
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 1:916 TALON DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OFALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:1500 E DOWNING ST STE 101
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3354
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3360786682081P2900X
OK352952081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine