Basic Information
| Provider Information | |||||||||
| NPI: | 1962498394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOMITA | ||||||||
| FirstName: | TADANORI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35422 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738804000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 N CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606143363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738804000 | ||||||||
| FaxNumber: | 7732811576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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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 | 207T00000X | 036061591 | IL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0563684 | 05 | IA | MEDICAID | 8023632 | 05 | WA | MEDICAID | 036061591 | 05 | IL | MEDICAID | 1627123 | 01 | IL | BCBS PROVIDER ID | OTHER | 7618592 | 01 | IL | GHI PROVIDER ID | OTHER |