=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013911403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS NICHOLAS DETESCO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7341 EISENHOWER DR
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-726-1138
-----------------------------------------------------
Fax | 330-726-6128
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7341 EISENHOWER DR
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-726-1138
-----------------------------------------------------
Fax | 330-726-6128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35100173D
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------