1215997077 NPI number — KEITH THOMPSON MD

Table of content: KEITH THOMPSON MD (NPI 1215997077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215997077 NPI number — KEITH THOMPSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
KEITH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1215997077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 KENNEDY DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MARTIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38237-3309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-587-5321
Provider Business Mailing Address Fax Number:
731-587-2145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 KENNEDY DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MARTIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38237-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-587-5321
Provider Business Practice Location Address Fax Number:
731-587-2145
Provider Enumeration Date:
03/24/2006

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: 208600000X , with the licence number:  18049 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 29386 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36655 . This is a "TLC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000188621 . This is a "UNISON" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3815542 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 07375201 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4128847 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4383459 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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