Basic Information
| Provider Information | |||||||||
| NPI: | 1407820772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NILL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10351 DAWSONS CREEK BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609691950 | ||||||||
| FaxNumber: | 2609182137 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 E DUPONT RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604366667 | ||||||||
| FaxNumber: | 2609182137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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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 | 208800000X | 01038992A | IN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0748972 | 05 | OH | MEDICAID | 000000087515 | 01 | IN | ANTHEM BC/BS | OTHER | 100329810 | 05 | IN | MEDICAID | 100081380 | 05 | IN | MEDICAID | 0825398 | 05 | OH | MEDICAID |