Provider Demographics
NPI:1750393328
Name:AFRICANO, THOMAS J (CRNA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:AFRICANO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-0158
Mailing Address - Country:US
Mailing Address - Phone:708-798-5838
Mailing Address - Fax:708-798-5865
Practice Address - Street 1:19624 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2077
Practice Address - Country:US
Practice Address - Phone:708-798-5838
Practice Address - Fax:708-798-5865
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003144207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL430004550OtherPALMETTO GBA/ RR MEDICARE
IL363175240OtherTAX I.D.
IL1617253OtherBCBS PROVIDER ID
IL0004241899OtherAETNA PIN
IL363175240OtherTAX I.D.