1962468926 NPI number — MR. THOMAS W FREE DO

Table of content: MR. THOMAS W FREE DO (NPI 1962468926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962468926 NPI number — MR. THOMAS W FREE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREE
Provider First Name:
THOMAS
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1962468926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-6585
Provider Business Mailing Address Fax Number:
605-328-6512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 W 18TH ST
Provider Second Line Business Practice Location Address:
STE LL03
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57104-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-328-1410
Provider Business Practice Location Address Fax Number:
605-328-1412
Provider Enumeration Date:
04/26/2006

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: 2085R0202X , with the licence number:  3356 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X , with the licence number: 3356 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7200340 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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