Provider Demographics
NPI:1730189176
Name:HAZEL, THOMAS R (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:HAZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3591
Mailing Address - Country:US
Mailing Address - Phone:630-232-2200
Mailing Address - Fax:630-232-1940
Practice Address - Street 1:2425 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3591
Practice Address - Country:US
Practice Address - Phone:630-232-2200
Practice Address - Fax:630-232-1940
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077708Medicaid
IL036077708Medicaid
ILL08751Medicare ID - Type UnspecifiedMEDICARE