Provider Demographics
NPI:1407946403
Name:CERVONI, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:CERVONI
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 1:789 EASTERN BYP
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2415
Mailing Address - Country:US
Mailing Address - Phone:859-624-4110
Mailing Address - Fax:859-624-1968
Practice Address - Street 1:789 EASTERN BYP
Practice Address - Street 2:SUITE 5
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2415
Practice Address - Country:US
Practice Address - Phone:859-624-4110
Practice Address - Fax:859-624-1968
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY34845207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY200312945OtherFEDERAL TAX ID
KY64035546Medicaid
5623185OtherAETNA PROVIDER ID
KYP00111547OtherTRAVELERS MEDICARE NUMBER
KY000000311405OtherANTHEM BLUECROSS & BLUESH
KY5245840001OtherDMEPOS ADMINISTAR
KY5245840001OtherDMEPOS ADMINISTAR
KY0796301Medicare ID - Type Unspecified
KYG26640Medicare UPIN
KY0796301Medicare PIN