Provider Demographics
NPI:1649248824
Name:MIENTUS, THOMAS F (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:F
Last Name:MIENTUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:STE 1895
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1895
Mailing Address - Country:US
Mailing Address - Phone:847-234-0049
Mailing Address - Fax:847-234-1946
Practice Address - Street 1:660 N WESTMORELAND
Practice Address - Street 2:LAKE FOREST HOSPITAL
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1696
Practice Address - Country:US
Practice Address - Phone:847-234-0049
Practice Address - Fax:847-234-1946
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084906207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL220021761OtherRR MCR
IL0360849066Medicaid
IL220021761OtherRR MCR
ILL54624Medicare ID - Type Unspecified