Basic Information
| Provider Information | |||||||||
| NPI: | 1265515019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENNVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304271775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126540475 | ||||||||
| FaxNumber: | 9126540486 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLENNVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304271775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127390475 | ||||||||
| FaxNumber: | 9126540486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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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 | 207Q00000X | 054519 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00379312 | 01 | RAILROAD MEDICARE | OTHER | 612221074F | 05 | GA | MEDICAID |