1205956364 NPI number — THOMAS J. SMALL, MD, INC.

Table of content: (NPI 1205956364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205956364 NPI number — THOMAS J. SMALL, MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS J. SMALL, MD, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205956364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 W JEFFERSON ST
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46131-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-736-9655
Provider Business Mailing Address Fax Number:
317-738-0922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 W JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46131-2147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-736-9655
Provider Business Practice Location Address Fax Number:
317-738-0922
Provider Enumeration Date:
03/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMALL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
317-736-9655

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25451 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100154600A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".