Provider Demographics
NPI:1194571133
Name:FITZGERALD, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 EAGLE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-2418
Mailing Address - Country:US
Mailing Address - Phone:865-308-0075
Mailing Address - Fax:561-634-2874
Practice Address - Street 1:915 EAGLE VIEW DR
Practice Address - Street 2:
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764-2418
Practice Address - Country:US
Practice Address - Phone:865-308-0075
Practice Address - Fax:561-634-2874
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist