Provider Demographics
NPI:1629038153
Name:CHURCH, THOMAS WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:CHURCH
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 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-227-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0490942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0758836Medicaid
OH000000177812OtherANTHEM BCBS
OH300044081OtherRAILROAD MEDICARE
OH300117621OtherRAILROAD MEDICARE
A17507Medicare UPIN
OH0758836Medicaid