Provider Demographics
NPI:1487628079
Name:PENROACH, THOMAS T (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
Last Name:PENROACH
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 1:7408 COASTAL HWY
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-2936
Mailing Address - Country:US
Mailing Address - Phone:410-524-0075
Mailing Address - Fax:410-524-0066
Practice Address - Street 1:7408 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-2936
Practice Address - Country:US
Practice Address - Phone:410-524-0075
Practice Address - Fax:410-524-0066
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD12868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS974AH46Medicare ID - Type Unspecified
MDB66868Medicare UPIN