Provider Demographics
NPI:1316202898
Name:POGUE, THOMAS W
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:POGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:W
Other - Last Name:POGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:287 N. LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:847-566-5350
Mailing Address - Fax:847-566-5392
Practice Address - Street 1:287 N. LAKE ST
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060
Practice Address - Country:US
Practice Address - Phone:847-566-5350
Practice Address - Fax:847-566-5392
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019012264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6906520001Medicare NSC