Basic Information
| Provider Information | |||||||||
| NPI: | 1215997077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 KENNEDY DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315875321 | ||||||||
| FaxNumber: | 7315872145 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 KENNEDY DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315875321 | ||||||||
| FaxNumber: | 7315872145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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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 | 208600000X | 18049 | MS | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 29386 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 36655 | 01 | TN | TLC | OTHER | 000000188621 | 01 | TN | UNISON | OTHER | 3815542 | 05 | TN | MEDICAID | 07375201 | 05 | MS | MEDICAID | 4128847 | 01 | TN | BCBS | OTHER | 4383459 | 01 | TN | AETNA | OTHER |