Provider Demographics
NPI:1376589481
Name:THOMAS A FISK MD
Entity Type:Organization
Organization Name:THOMAS A FISK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:NEW INTERLOCHEN PEDIATRICS
Mailing Address - Street 2:846 LAKE HOWELL RD
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NEW INTERLOCHEN PEDIATRICS
Practice Address - Street 2:846 LAKE HOWELL RD
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:407-767-2477
Practice Address - Fax:407-834-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61050332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58690100Medicaid
1084312OtherOTHER ID NUMBER-COMMERCIAL NUMBER