Provider Demographics
NPI:1932286481
Name:BRIDGE, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BRIDGE
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 1:3750 LANDMARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6633
Mailing Address - Country:US
Mailing Address - Phone:765-448-4511
Mailing Address - Fax:765-447-8375
Practice Address - Street 1:3750 LANDMARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6633
Practice Address - Country:US
Practice Address - Phone:765-448-4511
Practice Address - Fax:765-447-8375
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053690Medicaid
080159544Medicare PIN
IN100053690Medicaid
INB28124Medicare UPIN
IN160120DMedicare PIN