Provider Demographics
NPI:1558553248
Name:DOUGHERTY, THOMAS C (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-321-4333
Mailing Address - Fax:513-533-6033
Practice Address - Street 1:2139 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-321-4333
Practice Address - Fax:513-533-6033
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.09529363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCC2433OtherRAILROAD MEDICARE
KYCC2432OtherRAILROAD MEDICARE
OH2804022Medicaid
KY7100019060Medicaid
KYK074710Medicare PIN
OHCC2433OtherRAILROAD MEDICARE
KY7100019060Medicaid
OH1114950018Medicare NSC