Provider Demographics
NPI:1801892211
Name:HRISOMALOS, TOM F (MD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:F
Last Name:HRISOMALOS
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-331-3400
Mailing Address - Fax:812-332-7265
Practice Address - Street 1:550 LANDMARK AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-331-3400
Practice Address - Fax:812-332-7265
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032806A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100355020Medicaid
INB29453Medicare UPIN
IN100355020Medicaid