MEDICARE: THOMAS MCEVILLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1033925896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS MCEVILLY

Provider Business Mailing Address
First Line	:	5308 STONEHEDGE BLVD APT 6
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3055
Country	:	US
Telephone Number	:	812-606-1102
Fax Number	:

Provider Business Practice Location Address
First Line	:	5308 STONEHEDGE BLVD APT 6
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3055
Country	:	US
Telephone Number	:	812-606-1102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/06/2024

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Directions to “ THOMAS MCEVILLY ” Practice Location

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