Provider Demographics
NPI:1003379090
Name:FREIJE, THOMAS ROBERT (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:FREIJE
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 1:11530 ALLISONVILLE RD STE 190
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1862
Mailing Address - Country:US
Mailing Address - Phone:463-251-3937
Mailing Address - Fax:317-222-2332
Practice Address - Street 1:11530 ALLISONVILLE RD STE 190
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-1862
Practice Address - Country:US
Practice Address - Phone:463-251-3937
Practice Address - Fax:317-222-2332
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01087850A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN068010820OtherMEDICARE PTAN
IN1003379090OtherANTHEM PTAN
IN300026114Medicaid
IN264430E82OtherMEDICARE PTAN