Provider Demographics
NPI:1346225380
Name:WANNENBURG, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:WANNENBURG
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 1:9320 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4301
Mailing Address - Country:US
Mailing Address - Phone:865-373-7100
Mailing Address - Fax:865-373-7101
Practice Address - Street 1:9320 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4301
Practice Address - Country:US
Practice Address - Phone:865-373-7100
Practice Address - Fax:865-373-7101
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34761207RC0000X, 207RC0001X
TN52414207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016063Medicaid
8490OtherPARTNERS
85591OtherBCBS
SCQ24553Medicaid
WV2005393000Medicaid
NC8985591Medicaid
VA6013228Medicaid
5692360OtherAETNA
60067968OtherRR MEDICARE
60616OtherMEDCOST
5692360OtherAETNA
60067968OtherRR MEDICARE
SCQ24553Medicaid