Basic Information
| Provider Information | |||||||||
| NPI: | 1104820059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACABOBBY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | DONALD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8423 MARKET ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445126778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307298700 | ||||||||
| FaxNumber: | 3307298701 | ||||||||
| Practice Location | |||||||||
| Address1: | 8423 MARKET ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445126778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307298700 | ||||||||
| FaxNumber: | 3307298701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-085267 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2551886 | 05 | OH | MEDICAID | H143780 | 01 | OH | MEDICARE PTAN | OTHER |