Provider Demographics
NPI:1609855626
Name:PANKE, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:PANKE
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 632242
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-872-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033310207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
220014347OtherRAILROAD MEDICARE
IN200083240AMedicaid
IN200083240DMedicaid
IN200083240FMedicaid
IN200083240CMedicaid
OH0527308Medicaid
KY64935919Medicaid
IN200083240EMedicaid
OHPA0834044Medicare ID - Type Unspecified
F10570Medicare UPIN
IN200083240DMedicaid
OHPA0834043Medicare ID - Type Unspecified
KY64935919Medicaid