Provider Demographics
NPI:1093991861
Name:THOMAS JOSEPH JENNINGS MD
Entity Type:Organization
Organization Name:THOMAS JOSEPH JENNINGS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-982-4020
Mailing Address - Street 1:2824 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2478
Mailing Address - Country:US
Mailing Address - Phone:269-982-4020
Mailing Address - Fax:269-982-4017
Practice Address - Street 1:2824 S STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2478
Practice Address - Country:US
Practice Address - Phone:269-982-4020
Practice Address - Fax:269-982-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055947207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0110107OtherBLUE CROSS BLUE SHIELD MI
MI0809937OtherSECURE HORIZON
MI329013810Medicaid
MIE93150Medicare UPIN
MI329013810Medicaid
MI0809937OtherSECURE HORIZON