Healthcare Provider Details

I. General information

NPI: 1922030592
Provider Name (Legal Business Name): THOMAS M SHIRCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 BRADENTON AVE SUITE C
DUBLIN OH
43017-7532
US

IV. Provider business mailing address

4925 BRADENTON AVE SUITE C
DUBLIN OH
43017-7532
US

V. Phone/Fax

Practice location:
  • Phone: 614-336-7666
  • Fax: 614-336-7682
Mailing address:
  • Phone: 614-336-7666
  • Fax: 614-336-7682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number34002905
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: