1336117795 NPI number — MR. EDWARD BRENT THOMPSON ATC

Table of content: MR. EDWARD BRENT THOMPSON ATC (NPI 1336117795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336117795 NPI number — MR. EDWARD BRENT THOMPSON ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
EDWARD
Provider Middle Name:
BRENT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
1336117795
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:
1005 MEADOWLARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-985-2025
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INTERCOLLEGIATE ATHLETICS, SIU ARENA, RM. 118
Provider Second Line Business Practice Location Address:
SOUTHERN ILLINOIS UNIVERSITY
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-6620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-453-5161
Provider Business Practice Location Address Fax Number:
618-453-4173
Provider Enumeration Date:
03/10/2006

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: 2255A2300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com