1174620157 NPI number — RODNEY HOWARD THILL MD

Table of content: RODNEY HOWARD THILL MD (NPI 1174620157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174620157 NPI number — RODNEY HOWARD THILL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THILL
Provider First Name:
RODNEY
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174620157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 W 95TH STREET
Provider Second Line Business Mailing Address:
SUITE 413
Provider Business Mailing Address City Name:
OAK LAWN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-346-4055
Provider Business Mailing Address Fax Number:
708-499-0948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 W 95TH STREET
Provider Second Line Business Practice Location Address:
SUITE 413
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-346-4055
Provider Business Practice Location Address Fax Number:
708-499-0948
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  036085871 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036085871 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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