Basic Information
Provider Information | |||||||||
NPI: | 1104884311 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ISAACSON | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 98978 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891938978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7022163346 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10105 BANBURRY CROSS DR STE 250 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891446648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023607600 | ||||||||
FaxNumber: | 7023633814 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 09/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 4664 | SD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 19546 | NV | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 4664 | SD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 32847 | WI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 32847 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 103715 | 01 |   | UCARE | OTHER | 51B19IS | 01 | MN | MN BCBS | OTHER | 538R81IS | 01 | MN | MN BLUE SHIELD | OTHER | 143763100 | 05 | MN |   | MEDICAID | 931451029037 | 01 |   | PREFERRED ONE | OTHER | 0529776 | 05 | IA |   | MEDICAID | 0006848 | 01 | SD | SD BCBS | OTHER | 25-00471 | 01 |   | SELECTCARE | OTHER | 60057719 | 05 | SD |   | MEDICAID | 25118 | 01 | IA | IA BCBS | OTHER | 35614 | 01 |   | HEALTH PARTNERS | OTHER |