MEDICARE: THOMAS P VAN DEN DRIESSCHE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01028709A	IN

General Provider Information

NPI Number	:	1073507745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS P VAN DEN DRIESSCHE M.D.

Provider Business Mailing Address
First Line	:	3030 LAKE AVE
Second Line	:	SUITE 32
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5428
Country	:	US
Telephone Number	:	260-424-3134
Fax Number	:	260-424-3138

Provider Business Practice Location Address
First Line	:	3030 LAKE AVE
Second Line	:	SUITE32
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5428
Country	:	US
Telephone Number	:	260-424-3134
Fax Number	:	260-424-3138

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	11/14/2007

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