Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0129X | Vascular Surgeon | 02002492A | IN |
Y | 2086S0129X | Vascular Surgeon | 036094341 | IL |
NPI | 1043215148 |
---|---|
Provider Name | Dr. Eugene M Tanquilut |
First Address | Olympia Fields, IL 60461-1029 |
Second Address | Olympia Fields, IL 60461-1029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2005 |
Last Update Date | 03/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036094341 | (05) | IL |
G37906 | (02) | IN |