Provider Demographics
NPI:1396721270
Name:VERVILLE, THOMAS D (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:VERVILLE
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 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-331-9669
Mailing Address - Fax:704-331-0736
Practice Address - Street 1:4539 HEDGEMORE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3276
Practice Address - Country:US
Practice Address - Phone:704-331-9669
Practice Address - Fax:704-331-0736
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300359207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985057Medicaid
SCN00359Medicaid
NC1396721270Medicaid
NCNCF960AMedicare PIN
NC1396721270Medicaid
NC2190880CMedicare PIN