Provider Demographics
NPI:1386604874
Name:TAMBOURATZIS, THOMAS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:TAMBOURATZIS
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 1:1000 PARK PLACE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-2064
Mailing Address - Country:US
Mailing Address - Phone:724-229-7570
Mailing Address - Fax:
Practice Address - Street 1:1000 PARK PLACE DR STE 209
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2064
Practice Address - Country:US
Practice Address - Phone:724-229-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD460161207R00000X
IL036093387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633639OtherBLUE CROSS
IL205311Medicare ID - Type Unspecified
G53690Medicare UPIN