1528035409 NPI number — MR. MICHAEL DOUGLAS TOMPKINS LCAS

Table of content: MR. MICHAEL DOUGLAS TOMPKINS LCAS (NPI 1528035409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528035409 NPI number — MR. MICHAEL DOUGLAS TOMPKINS LCAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOMPKINS
Provider First Name:
MICHAEL
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCAS
Provider Gender Code:
M

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:
1528035409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
895 STATE FARM RD
Provider Second Line Business Mailing Address:
SUITE 508
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28607-4917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-372-4095
Provider Business Mailing Address Fax Number:
828-262-5687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 HWY 18 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28675-8478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-372-4095
Provider Business Practice Location Address Fax Number:
828-262-5687
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  66 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6111829 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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