Provider Demographics
NPI:1356327613
Name:RADICE, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:RADICE
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 1:3292 DIXIE RD SW
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0007
Mailing Address - Country:US
Mailing Address - Phone:812-764-5322
Mailing Address - Fax:
Practice Address - Street 1:3292 DIXIE RD SW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-0007
Practice Address - Country:US
Practice Address - Phone:812-764-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049054A207P00000X, 207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G81923Medicare UPIN