1083649370 NPI number — TOMMY D THOMAS PAC

Table of content: TOMMY D THOMAS PAC (NPI 1083649370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083649370 NPI number — TOMMY D THOMAS PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
TOMMY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1083649370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE PT
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PATEWOOD DR
Provider Second Line Business Practice Location Address:
STE C 100
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-3593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-454-7422
Provider Business Practice Location Address Fax Number:
864-454-7374
Provider Enumeration Date:
07/12/2006

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: 363AS0400X , with the licence number:  866 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0050PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00802365 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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