1336499151 NPI number — GEORGE THEKKANATTU THOMAS PA-C

Table of content: GEORGE THEKKANATTU THOMAS PA-C (NPI 1336499151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336499151 NPI number — GEORGE THEKKANATTU THOMAS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
GEORGE
Provider Middle Name:
THEKKANATTU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1336499151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8163 MANDAN TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENBELT
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20770-2643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-247-0844
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BUILDING 140 CAMPUS DRIVE
Provider Second Line Business Practice Location Address:
UNIVERSITY HEALTH CENTER
Provider Business Practice Location Address City Name:
COLLEGE PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-314-8095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2012

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: 363AM0700X , with the licence number:  C0004724 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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