Provider Demographics
NPI:1407849094
Name:PENDERGAST, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:PENDERGAST
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:PO BOX 3036
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3036
Mailing Address - Country:US
Mailing Address - Phone:812-231-4608
Mailing Address - Fax:812-231-4675
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-231-4608
Practice Address - Fax:812-231-4675
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039492207L00000X
IN01039492A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466090Medicaid
INE92061Medicare UPIN
IN183420Medicare PIN
IN226030AMedicare PIN