1376510529 NPI number — DR. FREDERICK W. THOM MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376510529 NPI number — DR. FREDERICK W. THOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOM
Provider First Name:
FREDERICK
Provider Middle Name:
W.
Provider Name Prefix Text:
DR.
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:
1376510529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 CABALLEROS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-7908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-549-7930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
877 OAK PARK BLVD.
Provider Second Line Business Practice Location Address:
MED PLUS MEDICAL CENTER
Provider Business Practice Location Address City Name:
PISMO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-474-8450
Provider Business Practice Location Address Fax Number:
805-474-8454
Provider Enumeration Date:
03/07/2006

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: 207Q00000X , with the licence number:  G61780 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 240629 . This is a "BLUE CROSS WORKERS COMP K" identifier . This identifiers is of the category "OTHER".
  • Identifier: DF2146 . This is a "RAILROAD MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5255526 . This is a "PPNI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0217529 . This is a "WASHINGTON STATE DOL PROV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 240630 . This is a "BLUE CROSS WORKERS COMP S" identifier . This identifiers is of the category "OTHER".
  • Identifier: G61780 . This is a "LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 235229 . This is a "BLUE CROSS WORKERS COMP P" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00347364 . This is a "RAILROAD MEDICARE PIN" identifier . This identifiers is of the category "OTHER".




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