1780713842 NPI number — MS. MADONNA RENEE THOMAS PT

Table of content: ALEXIA THOMPSON (NPI 1689479834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780713842 NPI number — MS. MADONNA RENEE THOMAS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
MADONNA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1780713842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 STANLEY GAULT PKWY STE 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-253-4919
Provider Business Mailing Address Fax Number:
502-489-5751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7725 HIGHWAY 62 STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47111-9676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-256-2147
Provider Business Practice Location Address Fax Number:
812-256-2252
Provider Enumeration Date:
03/05/2007

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: 225100000X , with the licence number:  001334 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 05002013A , 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: 000000230208 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200432370 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00069385 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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