1629299268 NPI number — GLEN THOMPSON III CSA

Table of content: GLEN THOMPSON III CSA (NPI 1629299268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629299268 NPI number — GLEN THOMPSON III CSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
GLEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
CSA
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:
1629299268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 RAVEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEREA
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-200-3356
Provider Business Mailing Address Fax Number:
502-451-9291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 RAVEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-200-3356
Provider Business Practice Location Address Fax Number:
502-451-9291
Provider Enumeration Date:
05/01/2007

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: 246ZS0410X , with the licence number:  2222 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000493588 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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