Provider Demographics
NPI:1104598754
Name:HENTRICH, THOMAS MARK (RNFA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:HENTRICH
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 CHOUTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4203
Mailing Address - Country:US
Mailing Address - Phone:618-402-7787
Mailing Address - Fax:
Practice Address - Street 1:12303 DEPAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041406201163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse