Basic Information
| Provider Information | |||||||||
| NPI: | 1073514360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EISEMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N. WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334721 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N WINFIELD ROAD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036102548 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 036102548 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3631498336019001 | 01 | IL | HFS GROUP PAYEE ID | OTHER | P00884750 | 01 | MEDICARE RAILROAD PTAN (INDIVIDUAL) | OTHER | 0222075 | 01 | IL | BLUE CROSS GROUP ID | OTHER | 036102548 | 05 | IL | MEDICAID | 206147 | 01 | IL | MEDICARE GROUP PTAN | OTHER | CA4748 | 01 | MEDICARE RAILROAD PTAN (GROUP) | OTHER | 1033149844 | 01 | IL | GROUP NPI | OTHER |