Provider Demographics
NPI:1538428586
Name:THOMAS A. WROBLEWSKI, M.D., S.C.
Entity type:Organization
Organization Name:THOMAS A. WROBLEWSKI, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WROBLEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-937-4404
Mailing Address - Street 1:401 N WALL ST
Mailing Address - Street 2:STE. 102
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2934
Mailing Address - Country:US
Mailing Address - Phone:815-937-4404
Mailing Address - Fax:815-937-4516
Practice Address - Street 1:401 N WALL ST
Practice Address - Street 2:STE. 102
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2934
Practice Address - Country:US
Practice Address - Phone:815-937-4404
Practice Address - Fax:815-937-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067296207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC51030Medicare UPIN