Basic Information
| Provider Information | |||||||||
| NPI: | 1316990468 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TONKOVIC | ||||||||
| FirstName: | RUSS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1555 BARRINGTON RD STE 3200 | ||||||||
| Address2: | |||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601695035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478828448 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1555 BARRINGTON RD | ||||||||
| Address2: | DOB 3 SUITE 3200 | ||||||||
| City: | HOFFMAN ESTATES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601691019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478828448 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036-070718 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P00137229 | 01 | RAILROAD MEDICARE | OTHER | 036070718 | 05 | IL | MEDICAID |