MEDICARE: THOMAS CHARLES BALDACCHINO 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	207RC0000X	Cardiovascular Disease Physician	J0437	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8G4961	OTHER	TX	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1720057631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS CHARLES BALDACCHINO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 MEDICAL PKWY
Second Line	:
City	:	LAKEWAY
State	:	TX
Zip	:	78738-1791
Country	:	US
Telephone Number	:	512-654-1234
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/11/2022

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