Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 36064425 | IL |
NPI | 1205812047 |
---|---|
Provider Name | Thomas Glimp |
First Address | Lake Forest, IL 60045-1659 |
Second Address | Chicago, IL 60675-1001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2005 |
Last Update Date | 24/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36064425 | (05) | IL |
C51704 | (02) | IL |