Basic Information
| Provider Information | |||||||||
| NPI: | 1356393086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRCHNER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3461 FAIRLANE FARMS ROAD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Practice Location | |||||||||
| Address1: | 3461 FAIRLANE FARMS ROAD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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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 | 2085R0202X | ME 71412 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2523680-00 | 05 | FL | MEDICAID |