Basic Information
| Provider Information | |||||||||
| NPI: | 1518959865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'CONNELL | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 334 THOMAS MORE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593410288 | ||||||||
| FaxNumber: | 8593447482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593410288 | ||||||||
| FaxNumber: | 8593447482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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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 | 207R00000X | 33055 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 872928 | 01 | AETNA | OTHER | 64330558 | 05 | KY | MEDICAID | 021036000 | 01 | FEDERAL BLACK LUNG | OTHER | 0404223 | 01 | UNITED HEALTHCARE | OTHER | 000000044596 | 01 | ANTHEM | OTHER | 2466479 | 05 | OH | MEDICAID | 310674100 | 01 | US DEPT OF LABOR | OTHER | 50006692 | 01 | PASSPORT | OTHER | P00935617 | 01 | KY | RAIL ROAD MEDICARE | OTHER |