Basic Information
| Provider Information | |||||||||
| NPI: | 1073873154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 804 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479020804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2605 N LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01075375A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000949479 | 01 | IN | ANTHEM | OTHER | 201102390 | 05 | IN | MEDICAID |