Healthcare Provider Details

I. General information

NPI: 1386844405
Provider Name (Legal Business Name): THOMAS R FENNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST # 800904
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

1215 LEE ST # 800904
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-1946
  • Fax: 434-982-1545
Mailing address:
  • Phone: 434-924-1946
  • Fax: 434-982-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number4301090586
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101274382
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: