Basic Information
| Provider Information | |||||||||
| NPI: | 1326204850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RHEE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036112829 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2085R0202X | 01069738 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201022940 | 05 | IN | MEDICAID | 036112829 | 01 | IL | ILLINOIS STATE LICENSE | OTHER |