Provider Demographics
NPI:1407820772
Name:NILL, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:NILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:2512 E DUPONT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1675
Practice Address - Country:US
Practice Address - Phone:260-436-6667
Practice Address - Fax:260-918-2137
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038992A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0748972Medicaid
IN000000087515OtherANTHEM BC/BS
IN100329810Medicaid
IN100081380Medicaid
OH0825398Medicaid
INE93686Medicare UPIN
IN1811952070Medicare PIN
IN100081380Medicaid
IN135140Medicare PIN
OH0825398Medicaid
IN0335410013Medicare NSC
INCB9217Medicare PIN
IN340010539Medicare PIN
OH9928923Medicare PIN
IN136140IMedicare PIN