Provider Demographics
NPI:1023095999
Name:FISH, THOMAS TAYLOR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:TAYLOR
Last Name:FISH
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 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5935
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:4901 GRANDE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5935
Practice Address - Country:US
Practice Address - Phone:850-477-7042
Practice Address - Fax:850-474-9060
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70634207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL591-36248OtherBLUE CROSS BLUE SHIELD
FL050049613OtherMEDICARE RAILROAD
AL009962800Medicaid
FL31866OtherBLUE CROSS BLUE SHIELD
FL379978600Medicaid
FLZ188OtherHEALTH FIRST NETWORK
FL3186Medicare PIN
AL009962800Medicaid