Basic Information
| Provider Information | |||||||||
| NPI: | 1558553248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2139 AUBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133214333 | ||||||||
| FaxNumber: | 5135336033 | ||||||||
| Practice Location | |||||||||
| Address1: | 2139 AUBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133214333 | ||||||||
| FaxNumber: | 5135336033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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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 | 363L00000X | APRN.CNP.09529 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN.CNP.09529 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | CC2433 | 01 | OH | RAILROAD MEDICARE | OTHER | CC2432 | 01 | KY | RAILROAD MEDICARE | OTHER | 2804022 | 05 | OH | MEDICAID | 7100019060 | 05 | KY | MEDICAID |