Basic Information
| Provider Information | |||||||||
| NPI: | 1275534406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMODY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95279 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606945279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3815 HIGHLAND AVE | ||||||||
| Address2: | ADVOCATE GOOD SAMARITAN HOSPITAL | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302755900 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-099110 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036099110 | 05 | IL | MEDICAID |