1407946403 NPI number — THOMAS D CERVONI M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407946403 NPI number — THOMAS D CERVONI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CERVONI
Provider First Name:
THOMAS
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407946403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
789 EASTERN BYP
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40475-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-624-4110
Provider Business Mailing Address Fax Number:
859-624-1968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
789 EASTERN BYP
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40475-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-624-4110
Provider Business Practice Location Address Fax Number:
859-624-1968
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  34845 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X , with the licence number: 34845 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200312945 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64035546 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5623185 . This is a "AETNA PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00111547 . This is a "TRAVELERS MEDICARE NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000311405 . This is a "ANTHEM BLUECROSS & BLUESH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5245840001 . This is a "DMEPOS ADMINISTAR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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