Provider Demographics
NPI:1215731161
Name:THOMAS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 MAJOR AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2532
Mailing Address - Country:US
Mailing Address - Phone:312-607-5181
Mailing Address - Fax:
Practice Address - Street 1:950 MILWAUKEE AVE STE 236
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3778
Practice Address - Country:US
Practice Address - Phone:224-717-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209031558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily