Basic Information
Provider Information
NPI: 1003000134
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CIBULL
FirstName: THOMAS
MiddleName: LEE
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2650 RIDGE AVE
Address2: EVANSTON HOSPITAL
City: EVANSTON
State: IL
PostalCode: 602011718
CountryCode: US
TelephoneNumber: 8475702040
FaxNumber: 8477335315
Practice Location
Address1: 2650 RIDGE AVE
Address2: EVANSTON HOSPITAL
City: EVANSTON
State: IL
PostalCode: 602011718
CountryCode: US
TelephoneNumber: 8475702040
FaxNumber: 8477335315
Other Information
ProviderEnumerationDate: 08/31/2007
LastUpdateDate: 08/06/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0102X036120492ILY Allopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology

No ID Information.


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