Basic Information
Provider Information | |||||||||
NPI: | 1225015456 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOM | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 MAPLE SUMMIT RD | ||||||||
Address2: |   | ||||||||
City: | JERSEYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 62052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184988310 | ||||||||
FaxNumber: | 6186392017 | ||||||||
Practice Location | |||||||||
Address1: | 400 MAPLE SUMMIT RD | ||||||||
Address2: | PAIN CENTER | ||||||||
City: | JERSEYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 62052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184986402 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 09/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 2004005755 | MO | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | 036118645 | IL | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207LP2900X | 036.118645 | IL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 255414300 | 05 | MN |   | MEDICAID | 036118645 | 01 | IL | IL LICENSE | OTHER | 900068033 | 01 | IL | ESSENCE | OTHER | 752332 | 01 | IL | HEALTHLINK | OTHER | 900068033 | 01 | IL | TAX-ID# | OTHER | 08220357 | 01 | IL | BCBS GRP# | OTHER |