Healthcare Provider Details

I. General information

NPI: 1528592789
Provider Name (Legal Business Name): THOMAS FAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 STATE ROUTE 162
MARYVILLE IL
62062-8500
US

IV. Provider business mailing address

1831 CHESTNUT ST STE 650
SAINT LOUIS MO
63103-2236
US

V. Phone/Fax

Practice location:
  • Phone: 618-391-6140
  • Fax: 618-288-2164
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2020041595
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036160350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: