Provider Demographics
NPI:1811523632
Name:ERDEY, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ERDEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 SUNRISE CT
Mailing Address - Street 2:
Mailing Address - City:LODA
Mailing Address - State:IL
Mailing Address - Zip Code:60948-9749
Mailing Address - Country:US
Mailing Address - Phone:779-435-3916
Mailing Address - Fax:
Practice Address - Street 1:138 SUNRISE CT
Practice Address - Street 2:
Practice Address - City:LODA
Practice Address - State:IL
Practice Address - Zip Code:60948-9749
Practice Address - Country:US
Practice Address - Phone:779-435-3916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC69Medicaid