Basic Information
| Provider Information | |||||||||
| NPI: | 1346206042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOYLE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 DEER TRACKS TRAIL | ||||||||
| Address2: | STE 130 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148215600 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Practice Location | |||||||||
| Address1: | 9515 HOLY CROSS LANE | ||||||||
| Address2: | |||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185264511 | ||||||||
| FaxNumber: | 6185260556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2008 | ||||||||
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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 | 2085R0202X | 036063855 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0360838553 | 05 | IL | MEDICAID | 203315502 | 05 | MO | MEDICAID | 300024221 | 01 | RR MEDICARE | OTHER | 171979 | 01 | HEALTHLINK | OTHER | 3683855 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |