Provider Demographics
NPI:1144202037
Name:FENNELL, THOMAS B JR (OC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:FENNELL
Suffix:JR
Gender:M
Credentials:OC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 FREEPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:NATRONA NEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065
Mailing Address - Country:US
Mailing Address - Phone:724-230-0422
Mailing Address - Fax:724-230-0424
Practice Address - Street 1:1627 FREEPORT ROAD
Practice Address - Street 2:
Practice Address - City:NATRONA NEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065
Practice Address - Country:US
Practice Address - Phone:724-230-0422
Practice Address - Fax:724-230-0424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007383L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77125Medicare UPIN