Basic Information
| Provider Information | |||||||||
| NPI: | 1811959992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLITANO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 311 N WALNUT AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WOOD DALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308600035 | ||||||||
| FaxNumber: | 6308605262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036067328 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 01063986A | IN | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 036067328 | IL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 2232802 | 01 | IL | BCBS PROVIDER ID | OTHER | 036067328 | 05 | IL | MEDICAID | 02233112 | 01 | IL | BCBS PROVIDER ID | OTHER | 780000579 | 01 | IL | RAILROAD MEDICARE | OTHER | P00118649 | 01 | IL | RAILROAD MEDICARE | OTHER | P00460001 | 01 | IL | RAIL ROAD MEDICARE | OTHER |