Provider Demographics
NPI:1730285248
Name:JANICKI, THOMAS I (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:I
Last Name:JANICKI
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 74521
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:216-381-2223
Mailing Address - Fax:216-381-5975
Practice Address - Street 1:1611 S GREEN RD STE 216
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4123
Practice Address - Country:US
Practice Address - Phone:216-383-0100
Practice Address - Fax:216-383-6481
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042732207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A79624Medicare UPIN