1417959917 NPI number — SUEANN THOMAS NP

Table of content: SUEANN THOMAS NP (NPI 1417959917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417959917 NPI number — SUEANN THOMAS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
SUEANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1417959917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 775383
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-5383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-376-5315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47201-7090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-372-8426
Provider Business Practice Location Address Fax Number:
812-378-7777
Provider Enumeration Date:
08/15/2005

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: 363L00000X , with the licence number:  71001592A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000990887 . This is a "ANTHEM PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200511580 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790837789 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 144670 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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