Basic Information
Provider Information | |||||||||
NPI: | 1740273531 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZEGARSKI | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 SAINT CLAIR AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | OH | ||||||||
PostalCode: | 458852400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193001129 | ||||||||
FaxNumber: | 4193949575 | ||||||||
Practice Location | |||||||||
Address1: | 1010 HAGER ST | ||||||||
Address2: |   | ||||||||
City: | SAINT MARYS | ||||||||
State: | OH | ||||||||
PostalCode: | 458852421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193949579 | ||||||||
FaxNumber: | 4193949580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2005 | ||||||||
LastUpdateDate: | 08/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35065349 | OH | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 0105065 | 01 | OH | GROUP MEDICAID6/1/17 | OTHER | 2091883 | 05 | OH |   | MEDICAID | 1184652539 | 01 | OH | GROUP NPI AS OF 6/1/2017 | OTHER | 34-1689161 | 01 | OH | JTDM FAMILY PRACTICE LLC AS OF 6/1/2017 | OTHER |