1720106875 NPI number — BRADLEY S THOMPSON FAMILY LIMITED PARTNERSHIP NO ONE

Table of content: (NPI 1689707986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720106875 NPI number — BRADLEY S THOMPSON FAMILY LIMITED PARTNERSHIP NO ONE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY S THOMPSON FAMILY LIMITED PARTNERSHIP NO ONE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1720106875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-349-4494
Provider Business Mailing Address Fax Number:
662-349-4495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7464 TCHULAHOMA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-4494
Provider Business Practice Location Address Fax Number:
662-349-4495
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR OWNER
Authorized Official Telephone Number:
662-349-4494

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350044428 . This is a "RR MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 3045182 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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