Provider Demographics
NPI:1992803258
Name:THOMAS, AUDRA M (MD)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:M
Other - Last Name:HANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3313
Practice Address - Fax:217-383-4014
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41275-020207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI930080181OtherMEDICARE RAILROAD
WI32524200Medicaid
WI0122-68655Medicare ID - Type Unspecified
WI32524200Medicaid
IL208905091Medicare PIN
G98932Medicare UPIN
WI930080181OtherMEDICARE RAILROAD
WI0031-32350Medicare ID - Type Unspecified
IL6447860003Medicare NSC