Provider Demographics
NPI:1356367619
Name:PACICCO, THOMAS JOHN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:PACICCO
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 HARDING PL
Practice Address - Street 2:STE 5100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2826
Practice Address - Country:US
Practice Address - Phone:704-355-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500420207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
100015793OtherRAILROAD
NC1356367619Medicaid
NC8964781Medicaid
SCN00420Medicaid
NC64781OtherNCBCBS
100015793OtherRAILROAD
NC2211615CMedicare PIN
NC1356367619Medicaid
G06028Medicare UPIN
SCN00420Medicaid
NCNCQ089BMedicare PIN
NC2211615AMedicare PIN