Basic Information
| Provider Information | |||||||||
| NPI: | 1013970581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNING | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2786 SANDHURST DR | ||||||||
| Address2: | |||||||||
| City: | LEWIS CENTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430359367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406573731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 745 W STATE ST | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432221515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142242281 | ||||||||
| FaxNumber: | 6142218869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 3506761F | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 28478453001 | 01 | MEDICAL MUTUAL OF OHIO | OTHER | 2207463 | 05 | OH | MEDICAID | 060060628 | 01 | RAILROAD MEDICARE | OTHER | 2847815300 | 01 | OH | BUREAU OF WORKERS COM | OTHER | 2502117 | 01 | UNITED HEALTHCARE | OTHER | 00000000203679 | 01 | ANTHEM BCBS | OTHER | 060060628 | 01 | OH | RAILROAD MEDICARE | OTHER | 61238 | 01 | NATIONWIDE | OTHER |