=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417214214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS JAMES CORREDINE DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 DALE RD
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-674-8830
-----------------------------------------------------
Fax | 860-674-8984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 JORDAN LN STE 3
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06109-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-263-0253
-----------------------------------------------------
Fax | 860-263-0262
-----------------------------------------------------
=====================================================
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 | 055026
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 6151
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 55026
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------