Basic Information
| Provider Information | |||||||||
| NPI: | 1740394089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOESEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 VOLLMER ROAD | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084818883 | ||||||||
| FaxNumber: | 7084812917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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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 | 207V00000X | 036060738 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036060738 | 05 | IL | MEDICAID | 160022790 | 01 | R/R MEDICARE | OTHER |