Basic Information
Provider Information | |||||||||
NPI: | 1255394524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SWEENEY | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 615 N MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466011033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5746477459 | ||||||||
FaxNumber: | 5746473658 | ||||||||
Practice Location | |||||||||
Address1: | 615 N MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466011033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5746477459 | ||||||||
FaxNumber: | 5746473658 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2006 | ||||||||
LastUpdateDate: | 02/08/2018 | ||||||||
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 | 207P00000X | 5101021493 | MI | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 02001337 | IN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100333170A | 05 | IN |   | MEDICAID | 114340127 | 05 | MI |   | MEDICAID | 000000181698 | 01 | IN | ANTHEM | OTHER | 930101009 | 01 | IN | RAIL ROAD MEDICARE | OTHER |