Provider Demographics
NPI:1871521757
Name:NIELSEN, THOMAS EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EDWIN
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 GERIG DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6365
Mailing Address - Country:US
Mailing Address - Phone:309-862-4000
Mailing Address - Fax:309-862-4055
Practice Address - Street 1:3302 GERIG DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6365
Practice Address - Country:US
Practice Address - Phone:309-862-4000
Practice Address - Fax:309-862-4055
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065215202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05721369OtherBC/BS
ILK46463Medicare PIN
IL05721369OtherBC/BS