Basic Information
Provider Information | |||||||||
NPI: | 1114032372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DWYER | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2111 MIDLANDS CT | ||||||||
Address2: |   | ||||||||
City: | SYCAMORE | ||||||||
State: | IL | ||||||||
PostalCode: | 601783125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8157580000 | ||||||||
FaxNumber: | 8157567130 | ||||||||
Practice Location | |||||||||
Address1: | 2111 MIDLANDS CT | ||||||||
Address2: |   | ||||||||
City: | SYCAMORE | ||||||||
State: | IL | ||||||||
PostalCode: | 601783125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8157580000 | ||||||||
FaxNumber: | 8157588521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 10/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 016-003526 | IL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 01915167 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 016003526 | 05 | IL |   | MEDICAID | 0359580001 | 01 | IL | DMERC | OTHER | 008866 | 01 | IL | HEALTH ALLIANCE | OTHER | 480032269 | 01 | IL | RAILROAD MEDICARE | OTHER |