Provider Demographics
NPI:1346206042
Name:DOYLE, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:DOYLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRAIL
Mailing Address - Street 2:STE 130
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:9515 HOLY CROSS LANE
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230
Practice Address - Country:US
Practice Address - Phone:618-526-4511
Practice Address - Fax:618-526-0556
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360638552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360838553Medicaid
MO203315502Medicaid
300024221OtherRR MEDICARE
171979OtherHEALTHLINK
IL3683855OtherBLUE CROSS BLUE SHIELD
300024221Medicare PIN
F26998Medicare UPIN
ILL20219Medicare ID - Type Unspecified